TABOO OF CEREBRAL DEATH
FR. JACEK MARIA NORKOWSKI OP
Nobody will deny that the issue of transplantology is quite specific. We still find out about other triumphs and progresses in this sphere. On the other hand, some news are getting into the public opinion anew, which are less encouraging. Recently, the Polish Television TVN broadcast news that prof. Jan Talar, known for awakening and rehabilitating people who fell into coma, stated at an anaesthetist symposium in Poznań that ‘death of brainstem does not exist’, and that ‘doctors take organs from alive people’ and ‘that they do not rescue patients as intensively as they should’.
Later a press attack on prof. Talar in ‘Gazeta Wyborcza’ and on my humble person in ‘Dziennik trybuna’ took place. I call these publications an attack, as they avoid any professional discussion about coma or cerebral death, whereas they are abundant with personal attacks on disputants and are satisfied with repetitions of some comforting phrases from transplantology experts that everything is all right, organs are taken from the dead and there is no reason to worry. There is no mention about still reoccurring cases of people recognized as dead on the basis of the so-called neurologic criteria, and who later recovered their health. There is no mention about cases of ill people in whose situations there were demands from members of their families to give a consent to organ donation, and whose people survived and now lead a normal and active life. I described these situations also in my book entitled: ‘A human being dies only once’. These were the cases to which prof. Talar referred in his last pronouncement. There are a lot of such situations about which media in Poland and all over the world informed, but they do not make any impression on policy-makers. It seems that having raised others’ interest, these news disappear for some time, in order to reappear on the surface someday again.
What is the reason of this state of things? Why isn’t there any scientific debate? Why isn’t the Sejm interested in these issues, instead it devoted so much time to the problem of ritual slaughter? As we notice it is necessary to debate on the problem of animals’ suffering, so, why don’t we debate on the situation of patients in coma, and on whether care about them is sufficient? Wouldn’t it be an important issue? And in the existing Polish law, the provision about the so-called alleged consent which allows for taking organs from people who did not express their consents to be an organ donor? Shouldn’t this situation in Poland alarm suitable bodies like politicians, parliamentarians and senators, lawyers, priests and theologians, as well as representatives of various social organizations, workers and finally, the very doctors and everybody who take care of ill people?
Answering these questions it must be stated that everything points to the fact that the issue of taking organs for transplantation became a taboo, which must not be discussed in public. Precisely speaking, it is permitted to write and inform about other successes of transplantology, but it is not allowed to make criticism about the key issue here, which is the issue of cerebral death, that is, simply speaking – the issue: is the donor alive or not alive at the moment of taking his organs.
Diagnostic criteria of cerebral death
Medical examinations which are carried out in order to make such an important statement, are astonishingly minimal: it is only enough to state coma connected with apnea on the basis of simple tests done at a patient’s bed, which are to prove the lack of nervous impulses within head and the lack of abilities to breathe independently. Examination of apnea in Poland is based on turning off a respirator for 10 minutes and observing an ill person if he is trying to start breathing independently. This examination is strongly criticised by doctors dealing with the issue of cerebral death. They point to the fact that this examination is done to a patient who still has full rights as a patient. Hence, there is a duty to care about him, which obliges doctors to act only in the interest of a patient. Whereas, what good for a patient with his damaged brain can result from it, that he will be deprived of oxygen? For doctors it is clear that this examination is harmful for a patient, that it leads to the breakdown of blood circulation in his brain. In addition, it damages this organ and can lead to other complications, such as, for example, cardiac arrest. How is it possible that an examination defined as dangerous for a patient’s life is carried out, which may not bring any benefits? The only logical answer is as follows: A patient, before his cerebral death was recognized, had already been acknowledged as somebody who does not have any rights of a patient. On what basis? On the basis of a quiet agreement that ‘it will be the best solution’?
Transplantology experts, who publicly praise their achievements, as examinations carried out in the USA proved, do not declare their consent to be organ donors. So, there is a question: why don’t they consider good for themselves what is good for others? The only answer which comes to minds is banal: they know the best on what the procedure of stating the cerebral death is based, what is preparation of a donor for giving organs like and what is organs donation like. They know what this operation looks like, during which a thorax and ventral shell are cut, during which medications are applied which are needed for supporting blood circulation (the purpose is supply organs with blood before taking organs) and muscle relaxants, that is, medications preventing muscles from cramps, but it is not necessary to use anesthetics. This all is shrouded in mystery for the majority of the society.
Various interpretations of a diagnosis of cerebral death
It is also interesting that transplantology experts generally admit that they do not believe in the opinion that cerebral death is biological death, that is, the end of existence of a particular alive organism. They rather tend to say that ‘this body is still alive’, but ‘its owner is not in it any more’. Instead of an organic death, they prefer to speak about ‘irreversible loss of consciousness’.
For medicine, the question about the nature of consciousness and its relation to the human being became particularly essential from the moment when in 1968 the Harvard Committee acknowledged irreversible coma of a patient, connected with apnea tantamount to his death. The Committee did it for some reason not at that but at another moment. It was all about rescuing a colleague, Christian Barnard, who had done heart transplant a year before and who had been convicted of a doubled murder: both a donor and a recipient. At that time the Harvard Committee decreed that it acknowledged the appearing coma with apnea tantamount to human death, not giving any scientific justification for it. Whereas, it was openly written in a document, that its authors meant unblocking hospital beds occupied by patients in coma and a possibility of gaining organs from them for transplants. Later there was withdrawal from these declarations and there appeared explanations about the cerebral death as a successive process of the loss of the central integrator of the organism, which was to be a brain (A report of the Presidential Commission from 1981), and later there was a withdrawal also from this theory (A report of the Bio-ethical Commission for the President of the USA from 2008) also recommending unsuitable terms like ‘cerebral death’ and was replaced by a different one – ‘a complete dysfunction of the brain’.
The present status quo
However doctors got used to the concept of ‘cerebral death’ and this nomenclature is still used. So, the alleged death of brain (in fact brain is ischemic among some organ donors, but is not destroyed, and shows many functions) is supposed to lead to a postulated, that is, unrealistic death of organism as a whole, that is, death of the whole body. So, in order to fit into this scheme, there is an opinion despite the facts that it is seen with a bare eye, that the body of an organ donor became only a group of tissues and organs.
Nearly 1/3 members of transplant teams taking organs for transplants think that at the moment when organs are being taken, the organ donor is still alive. Also about 1/3 anaesthetics in Great Britain give organ donors anaesthetics during operations of taking organs in belief that they may feel pain. No wonder if they see normal reactions of organ donors’ bodies to applied medications, reactions, which do not differ from those ones observed among other ill people. In other words – despite using the term ‘corpses with beating heart’ by ‘Poltransplant’ and similar institutions in other countries, doctors working with these ‘corpses’ think them to be alive. However, everyone will admit that the ‘alive corpses’ is the term onto which it is not easy to agree.
Possibilities of treating ill people with brain injury
It is worrying that members of particular countries, and even their medical environments, were not informed that the state of ill people, defined as enabling to make suspicions, and later the recognition of cerebral death, is reversible within 48 hours from the moment of its appearing, according to some authors, provided that a suitable hypothermia is applied quickly as well as other kinds of therapy and not carrying out an attempt of apnea. Those authors state that within 60-70 percent of cases also full rehabilitation among those ill people is possible, that is, their return to their previously done tasks. We can also have new hopes relating to regeneration of organs which widens therapeutic possibilities also in reference to brain damage.
A problem of respecting civilian rights versus legal regulations concerning cerebral death
Legal regulations which are obliging in most countries of the world, are characterized by the lack of respect towards religious, worldly and ethical beliefs. At least this part of the society of these countries which does not recognize the cerebral death as the human death. A number of people thinking in this way is from 20 to 40 and more per cent in various countries. Therefore, in the opinion of many authors, it would be necessary to amend law provisions in these countries in such a way so that beliefs of citizens who do not agree with the concept of cerebral death or taking organs from organ donors with not beating heart would be respected.
A kind of a step forward would be going away from the principle of an alleged consent to taking organs for transplant and replacing it with a consent expressed personally by everybody in a positive way. In order to carry out such solutions the public debate on these issues is necessary, and, which is obvious, a political willingness.
An attitude of the Catholic Church
The attitude of the Catholic Church in the issue of the concept of cerebral death is characterized by a kind of ambiguity. Indeed John Paul II agreed to accept neurological criteria in his speeches, and during a congress of the Transplantology Society in Rome in 2000 he said that ‘the criteria accepted in the recent time, on whose basis death is stated, which is, complete and irreversible stop of brain activity, if it is rigorously applied, it does not seem to maintain in contradiction with essential assumptions of the reliable anthropology’. However, we should note that the phrase ‘does not seem to maintain in contradiction’ expresses a conditional character of the whole statement. This conditional character of the consent to the concept of cerebral death must have resulted from the fact that doctor’s environment, as a whole, is characterised by the lack of compatibility of opinions about the cerebral death. John Paul II reopened a debate a few months before his death, demanding to study the concept of the cerebral death again, and Benedict XVI ordered to continue it.
The Catholic Church defends the human life from conception to the natural death. In my opinion, the so-called cerebral death is not death at all, and death on an operating table in the role of an organ donor is not natural at all.