The Beating Heart Donors05.02.2012 They urinate. They have heart attacks
and bedsores. They have babies. They may even feel pain. Meet the organ
donors who are “pretty dead.”
by Dick Teresi
http://discovermagazine.com/2012/may/10-the-beating-heart-donors/article_view?b_start:int=3&-C
=
[image: heart removed for transplant]Donor Heart Procurement for Cardiac
Transplantation via
Shutterstock<
http://www.shutterstock.com/pic-43154983/stock-photo-donor-heart-procurement-for-cardiac-transplantation.html?src=csl_recent_image-15>
in 1968, thirteen men gathered at the Harvard Medical School to virtually
undo 5,000 years of the study of death. In a three-month period, the
Harvard committee (full name: the Ad Hoc Committee of the Harvard Medical
School to Examine the Definition of Brain Death) hammered out a simple set
of criteria that today allows doctors to declare a person dead in less time
than it takes to get a decent eye exam. A good deal of medical language was
used, but in the end the committee’s criteria switched the debate from
biology to philosophy. Before many years went by, it became accepted by
most of the medical establishment that death wasn’t defined by a heart that
could not be restarted, or lungs that could not breathe. No, you were
considered dead when you suffered a loss of personhood.
But before we see what substituting philosophy for science actually means
to real patients, let’s look at the criteria the Harvard authors believed
indicated that a patient had a “permanently nonfunctioning brain”:
• Unreceptivity and unresponsivity. “Even the most intensely painful
stimuli evoke no vocal or other response, not even a groan, withdrawal of a
limb or quickening of respiration,” by the committee’s standard.
• No movements or spontaneous breathing (being aided by a respirator does
not count). Doctors must watch patients for at least one hour to make sure
they make no spontaneous muscular movements or spontaneous respiration. To
test the latter, physicians are to turn off the respirator for three
minutes to see if the patient attempts to breathe on his own (the apnea
test).
• No reflexes. To look for reflexes, doctors are to shine a light in the
eyes to make sure the pupils are dilated. Muscles are tested. Ice water is
poured in the ears.
• Flat EEG <
http://en.wikipedia.org/wiki/Electroencephalography>. Doctors
should use electroencephalography, a test “of great confirmatory value,” to
make sure that the patient has flat brain waves.
The committee said all of the above tests had to be repeated at least 24
hours later with no change, but it added two caveats:
hypothermia<
http://en.wikipedia.org/wiki/Hypothermia>and drug
intoxication can mimic brain death. And since 1968, the list of
mimicking conditions has grown longer.
Despite heroic efforts to clarify and justify the definition of death, it
remains opaque, confusing, and inconsistent.
Although the Harvard criteria were based on zero patients and no
experiments were conducted either with humans or animals, they soon became
the standard for declaring people dead in several states, and in 1981,
the Uniform
Determination of Death
Act<
http://www.law.upenn.edu/bll/archives/ulc/fnact99/1980s/udda80.htm>(UDDA)
was sanctioned by the National
Conference of Commissioners on Uniform State
Laws<
http://en.wikipedia.org/wiki/National_Conference_of_Commissioners_on_Uniform_State_Laws>.
The UDDA is based on the Harvard Ad Hoc Committee’s report. That a
four-page article defining death should be codified by all 50 states within
13 years is staggering.
Just as some of our ancestors saw the heart as the locus of the soul, today
the medical establishment assumes that the brain is what defines humanity
and that a functioning brain is vital to what is called a human being’s
personhood. D. Alan Shewmon <
http://www.brainharmony.org/>, a pediatric
neurologist at UCLA who was originally pro–brain-death, now dismisses the
idea. The most scientific approach one can take to death, he says, is to
treat human beings like any other species. People should be judged
biologically on whether they are alive or dead, not on some vague notion of
personhood. There is no abstract notion of “squirrelness,” for example, or
“gorillahood,” by which we determine the death of other species.
The question is: Why do we even need concepts like personhood and brain
death? Despite heroic efforts to clarify and justify the Harvard criteria,
they remain opaque, confusing, and contradictory. If, as proponents say,
brain death criteria describe the same condition—i.e., death—as the
cardiopulmonary criteria, why bother? Especially since the tools are
available for declaring cardiopulmonary death, and are sorely lacking, or
at least ignored, for determining whether the whole brain is really dead.
Shewmon compiled 150 documented cases of brain-dead patients whose hearts
continued to beat, and whose bodies did not disintegrate, past one week’s
time. In one remarkable case, the patient survived 20 years after brain
death before succumbing to cardiac arrest.
+++
Brain-death advocates have always insisted that anyone who meets their
criteria will fall apart quickly, and go quickly to meet the
cardiopulmonary criteria. Yet Shewmon presents a litany of life processes
that brain-dead patients continue to exhibit:
• Cellular wastes continue to be eliminated, detoxified, and recycled.
• Body temperature is maintained, though at a lower-than-normal temperature
and with the help of blankets.
• Wounds heal.
• Infections are fought by the body.
• Infections produce fever.
• Organs and tissues continue to function.
• Brain-dead pregnant women can gestate a fetus.
• Brain-dead children mature sexually and grow proportionately.
So what drove the Harvard Ad Hoc Committee to turn back the calendar and
construct a lower standard for death? To a growing number of scientific
critics it appears that the committee was fixated on freeing up human
organs for transplant.
By the 1960s, thanks to significant advances in technology, these kinds of
transplants—once a staple of science fiction—had become a practical
reality. But to accomplish this morally and legally, a new definition of
death, one that enabled the organs to remain viable, had to be created.
Today the transplant industry is a $20 billion per year business. It spends
more than a billion dollars a year on immunosuppressive
drugs<
http://en.wikipedia.org/wiki/Immunosuppressive_drug>alone, which
prevent the recipient’s immune system from rejecting the
transplanted organ. Transplant surgeons are near the top of the M.D. food
chain, earning on average around $400,000 per year. They and their staffs
often fly to organ harvests on private jets. Finder’s fees, in the form of
“administrative costs,” are often paid to hospitals.
The only people who do not get a share of the transplant wealth are the
most essential: the donors and their families. By law, they are the only
ones who cannot be compensated. Joseph
Murray<
http://www.nobelprize.org/nobel_prizes/medicine/laureates/1990/murray.html>,
the surgeon who performed the first solid-organ transplant, maintains that
donors must not be paid, in order to maintain the integrity of the field.
The organ trade claims transplants are the neat extraction of body parts
from totally dead, unfeeling corpses. But it's more complicated and messier
than that.
It is the job of organ procurement organizations and their wranglers to
talk a family out of the organs belonging to a soon-to-be-dead son,
daughter, husband, wife, nephew, niece, or other relative. This must be one
of the toughest sales jobs in the world. Distraught parents whose child is
dead or dying must be asked to make yet another sacrifice. But it is that
very pain and confusion that helps organ procurement organizations ease
their way in.
Jim McCabe, senior donation coordinator for the New England Organ
Bank<
http://www.neob.org/>,
explains that “it’s a way of finding meaning in death, make the best of a
tragic situation. I’m going into the ICU to offer the family an option.”
The option most families want is to keep their loved one alive. A
brain-death team tells them that survival is not in the cards. Then McCabe
gives them another option: to keep someone else alive. His batting average
is excellent. He gets 50 to 60 percent of next of kin to agree.
Joanne Lynn<
http://www.altarum.org/experts/profiles-health-systems-research-professionals/joanne-lynn>,
M.D., a geriatrician and director of the Altarum Center for Elder Care and
Advanced Illness based in Washington, D.C., says, “Advocate groups just
want the organs. Transplant debate has ignored the donors and focused on
the recipients.”
Organ transplants would be peripheral to the story of death if they were
what the organ trade claimed them to be: the neat extraction of body parts
from totally dead, unfeeling corpses. But it is more complicated and
messier than that. The grisly facts compiled in this article are not an
attempt to derail organ transplantation—an impossible task, given how
entrenched the industry is—but knowledge that has been gained from the
medical establishment’s obsession with recycling the bodies of people who
are, in the words of Dr. Michael
DeVita<
http://www.wiser.pitt.edu/Sites/WISER/aboutus/bios/devita.asp>of
the University of Pittsburgh’s Medical Center, only “pretty dead.”
Or if you want to take a more optimistic point of view, these facts are
proof of the tenacious persistence of human life. Despite the Harvard Ad
Hoc Committee’s claims that its criteria for brain death and the
cardiopulmonary criteria describe the same phenomenon, beating-heart
cadavers (BHCs) are decidedly different from regular corpses. “I like my
dead people cold, stiff, gray, and not breathing,” says DeVita. “The brain
dead are warm, pink, and breathing. They look sick, not dead.”
Beating-heart cadavers were created as a kind of subspecies designed
specifically to keep organs fresh for their future owners. McCabe says
keeping the body alive from the brain stem down defeats warm ischemia, the
restriction or loss of blood flow after conventional death. When the
circulation stops, oxygen is no longer delivered to the organs, and cells
begin to die.
+++
McCabe says his outfit can get a donor from brain death to the operating
room in 12 hours. Sometimes it may take an hour after death is declared to
obtain consent, the ventilator being kept on while negotiations continue.
An hour later, a blood sample is drawn, and it takes eight hours to check
for AIDS, hepatitis, and cancer, all of which disqualify a BHC from
becoming a donor. Time is of the essence, because the beating-heart
cadaver—a brand new kind of creature, known only since the advent of brain
death—could easily have a heart attack and die again before his organs are
removed.
Once a patient goes brain dead, and relatives sign his organ donation
consent form, he will get the best medical care of his life. Code blues in
hospitals may be a call for doctors to rush to the bedside of beating-heart
cadavers who need their hearts defibrillated. BHCs are also routinely
turned in their beds so they don’t get bedsores. Their kidneys are treated
to avoid renal failure. Fluids are administered constantly to avoid diabetes
insipidus <
http://en.wikipedia.org/wiki/Diabetes_insipidus>, among other
things; a healthy BHC should pee out 100 to 250 milliliters of urine per
hour. The lungs have to be monitored to keep them in shape for the next
owner, and mucous is removed.
Steven Ross <
http://www.cooperhealth.org/physicians/steven-e-ross-md> of
Cooper University Hospital in Camden, New Jersey, and Dan Teres of Baystate
Medical Center <
http://baystatehealth.com/Baystate> in Springfield,
Massachusetts, both say keeping BHCs “alive” is an arduous task for
hospital nurses and other workers. Ross says it takes “very aggressive
care.” But that they can be medically cared for at all, as Alan Shewmon
demonstrated with his 150 cases, gives one pause about the validity of
their deaths.
There is more than one way to harvest a beating-heart cadaver. McCabe’s
outfit uses a team of seven in the operating room: one surgeon, one
resident, one technician from the organ bank, one coordinator from the ICU,
two nurses, and one anesthesiologist. Some teams may add another surgeon if
many organs are being extracted.
In a typical dissection, a midline incision is made from just below the
neck to the pubic area. The sternum is split with an electric saw or a Lebsche
knife <
http://www.flickr.com/photos/65837114_at_N00/40419482/>, a chisel-like
instrument the doctor hits with a mallet. A sternal
retractor<
http://www.mpoullis.com/thorcd/ctsnet/ss.htm>with spikes is
used to open the sternum. Sometimes the
aorta <
http://en.wikipedia.org/wiki/Aorta> is clamped at the beginning of
the harvest, and the blood replaced with a coolant to avoid clots and
stabilize temperature. Traditionally, the donor’s blood is simply left in
place.
Mark Schlesinger does not like his patients to feel pain during
conventional surgery. He is chairman of the department of
anesthesiology at Hackensack
University Medical Center <
http://www.hackensackumc.org/> in New Jersey,
and he points out that an anesthesiologist creates brain-dead patients
every day: “We give drugs to make them die. And we bring them back [when
the surgery is completed].” A patient under anesthesia is one of the many
growing exceptions to the Harvard criteria. He would meet the criteria on
the surface, but would be disqualified (ruled still alive) if the examining
doctor knew his system was full of drugs. “The only test you fail under
anesthesia,” Schlesinger says, “is irreversibility.” That is, if an
anesthetized patient has had his brain stem put down temporarily. A
brain-dead organ donor’s brain stem is also down—but we do not know, given
the limitations of the Harvard criteria and their focus entirely on the
brain stem, what is going on with the donor’s cerebral cortex or everything
beyond the brain stem.
Anesthesiologists have been at the forefront of questioning the finality of
brain death and whether beating-heart cadavers truly are unfeeling, unaware
corpses. They have also begun wondering about what a “pretty dead” donor
may experience during a three- to five-hour harvest sans anesthetic, and
they are speaking out on the subject.
Gail A. Van Norman<
http://medical.washington.edu/bios/view.aspx?CentralId=29374>,
a professor of anesthesiology and bioethics at the University of
Washington, cites some disturbing cases.
In one, an anesthesiologist administered a drug to a BHC to treat an
episode of tachycardia <
http://en.wikipedia.org/wiki/Tachycardia> during a
harvest. The donor began to breathe spontaneously just as the surgeon
removed his liver. The anesthesiologist reviewed the donor’s chart and
found that he had gasped at the end of an apnea test, but a neurosurgeon
had declared him dead anyway.
In another case, a 30-year-old patient with severe head trauma was declared
brain dead by two doctors. Preparations were made to excise his organs. The
on-call anesthesiologist noted that the beating-heart cadaver was breathing
spontaneously, but the declaring physicians said that because he was not
going to recover he could be declared dead. The harvest proceeded over the
objections of the anesthesiologist, who saw the donor move and react to the
scalpel with hypertension that had to be treated. It was in vain since the
proposed liver recipient died before he could get the organ, which went
untransplanted.
And in a third instance, a young woman suffered seizures several hours
after delivering her baby. A neurologist said it was a “catastrophic
neurologic event,” and she was readied for harvest. At that time the
anesthesiologist found that she had small yet reactive pupils, weak corneal
reflexes, and a weak gag reflex. After treatment, “the patient coughed,
grimaced, and moved all extremities.” She regained consciousness. She
suffered significant neurologic deficits but was alert and oriented.
+++
The brain-death establishment discounts such stories as “anecdotal,” as if
they were taken from the *National Enquirer*. But these three cases
appeared in *Anesthesiology<
http://journals.lww.com/anesthesiology/pages/default.aspx>
*, the journal of the American Society of Anesthesiologists, which has
44,000 members.
The Harvard criteria state that the brain-dead patient must exhibit no
movement. Van Norman, however, points out that some exhibit spinal
automatism<
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0447.1926.tb11030.x/abstract>,
a complex spectrum of movements including flexion of limbs and trunk,
stepping motions, grasping motions, and head turning. Dr. Gregory Liptak,
in the *Journal of the American Medical Association*,
wrote<
http://jama.ama-assn.org/content/255/15/2028.2.extract>:
“Patients who are brain dead often have unusual spontaneous movements when
they are disconnected from their ventilators.... Goose bumps, shivering,
extensor movements of the arms, rapid flexion of the elbows, elevation of
the arms above the bed, crossing of the hands, reaching of the hands toward
the neck, forced exhalation, and thoracic respiratory-like movements...
These complex sequential movements are felt to be release phenomena from
the spinal cord including the upper cervical cord and *do not* [emphasis
author’s] mean that the patient is no longer brain dead.”
One cannot determine with certainty what organ donors feel, if anything,
while being harvested. The logic of brain death goes like this: If the
brain stem is dead, then the higher centers of the brain are also probably
dead, and if the whole brain is dead, then everything beneath the brain
stem is no longer relevant. Since in practice only the brain stem is
routinely tested, the vast majority of the body, everything above the brain
stem and everything below, no longer counts as human.
The reason for denying beating-heart cadavers anesthetic during the removal
of their organs is hard to pin down. (Some experts say it is because
anesthetic will harm the organs.) Nevertheless, administering anesthetics
to BHCs during organ harvests is becoming more common in Europe, according
to Robert Truog <
http://medethics.med.harvard.edu/people/truog/>, professor
of medical ethics, anesthesia, and pediatrics at Harvard Medical School.
Despite their strong opposition to brain death, Truog and Shewmon both
refuse to acknowledge the possibility that some donors may be in severe
pain during organ harvests, even though they acknowledge that some donors
did exhibit reactions similar to inadequately anesthetized surgical
patients who afterward reported pain and consciousness. Shewmon said the
donor reactions were simply “bodily reactions to noxious stimuli.” I asked
if an experiment could be designed to answer the question of pain in
donors. He said no.
Truog did not even want to discuss the possibility of pain in the organ
donor. But when I suggested experiments along the lines suggested by other
anesthesiologists—when BHCs show pain reactions during a harvest,
administer anesthetic to see if the reactions subside—he surprised me by
saying he had already done this. He has used two different kinds of
anesthetics that do not harm organs to quell symptoms such as high blood
pressure or heart rate. “Just because the symptoms come down, though,” he
added, “does not mean the patient is in pain. Pain is a subjective thing.”
As with Shewmon, I asked Truog if an experiment wasn’t called for. He said
there was no experiment that could answer the question of pain in the donor.
Beyond pain, there are many surprising findings in a 1971 paper, “Brain
Death: A Clinical and Pathological
Study<
http://thejns.org/doi/abs/10.3171/jns.1971.35.2.0211?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed>,”
published in the* Journal of Neurosurgery*. The Minnesota team that
produced that article studied 25 moribund patients, conducting autopsies on
them all and EEGs on some. They also checked for reflexes and found
something unusual. Five of the 25 brain-dead people were still sexually
responsive. The researchers gently stroked the “nipple and areola” of all
patients and got responses from five, four men and one woman. Then they
stroked the skin at the root of the penis on the 18 male patients, and four
responded with “gentle seesaw movements of the penis.” The researchers felt
this reaction was “an incomplete or abortive form of penile erection.”
Abortive or not, to the untrained eye it would appear to be a sign of life.
More dramatic are brain-dead pregnant women. The first recorded case
occurred in 1981 when a 24-year-old woman, 23 weeks pregnant, was admitted
to the Women and Children’s Hospital of Buffalo. After 18 days her EEG
showed no cerebral activity and she was transferred to a maternity
hospital. A day later she was declared brain dead, approximately 25 weeks
pregnant. So she was dead but still pregnant, and doctors decided to use
her body—technically it was a corpse—as an incubator. The task was not
easy. She developed diabetes insipidus, sinus
tachycardia<
http://en.wikipedia.org/wiki/Sinus_tachycardia>,
and uterine contractions. Later she had wide fluctuations in blood
pressure, and the fetus’s heart rate was dropping. A cesarean section was
performed immediately, delivering a 2-pound “vigorous” baby girl at about
the 26th week of gestation. Three months later the infant was discharged
from the hospital, weighing about 4.4 pounds.
Six months earlier, another pregnant woman in desperate straits was
admitted to the same hospital, with a very different ending. The doctors
discontinued life support short of brain death as the fetus was 19 weeks
old, and the medical staff accepted the belief that a body could not
survive long after brain death was declared. There was theoretically not
time to gestate the fetus another 3 weeks, 22 weeks being the earliest a
viable baby can be delivered.
More brain-dead pregnant moms followed. As of this writing there have been
22 published reports from around the world, including Brazil, Germany,
Ireland, New Zealand, France, Finland, Korea, Spain, and the United States.
>From these 22 brain-dead mothers, 20 babies were produced, with no
remarkable side effects in the infants. One woman gestated a fetus for 107
days after declaration of brain death.
The real significance of pregnant brain-dead women is that they would seem
to sound the death knell for brain death as a definition. As Shewmon and
many others have pointed out, what is more indicative of life than
gestating a baby to a live and viable birth? Keeping a pregnant mother and
baby “alive” for 107 days at the very least puts the lie to the theory that
the brain dead will go quickly to conventional heart/lung death. At first,
brain death advocates said this is a matter of hours. Then they said 3 to 5
days at the most. Then 7 days, then 9 days, then 14 days. Now we are
talking about a brain-dead mother not only hanging on for 107 days but
nourishing a baby as well.
A final note: Brain-dead mothers can still donate their organs. And so,
after suffering a neurological catastrophe, being declared dead, still
having to endure several weeks of pregnancy, then giving birth via cesarean
section, the patient can still be rolled off to have her organs removed. A
woman’s work is never done.
------------------------------
*Excerpted from *The Undead: Organ Harvesting, the Ice-Water Test,
Beating-Heart Cadavers—How Medicine Is Blurring the Line Between Life and
Death<
http://www.amazon.com/The-Undead-Harvesting-Ice-Water-Cadavers-How/dp/0375423710>
* by Dick Teresi. Published by Pantheon Books, a division of Random House.
Copyright © 2012 by Dick Teresi. Excerpted by permission.*
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Received on Sat May 05 2012 - 22:30:57 EDT
