|
Chapter Eight: Brain
Death, Organ Transplants and Non-Heart Beating Organ Donor Protocols
Sally Suntori found her mother, Betty Lou Gibson, face downward
and unresponsive, in her apartment bathroom. Sally activated 911,
and the paramedics arrived in six minutes to transport her to Samaritan
Medical Center. She was breathing shallowly, and had a thready pulse.
By the time Sally arrived at the hospital, her mother was already
on a ventilator in the Intensive Care Unit, still unresponsive.
Her pupils did not react, she had no spontaneous movements or other
"brainstem signs", but as long as the ventilator functioned
her blood gases were okay, and her pulse and blood pressure stayed
stable.
The neurologist, Dr. Sue Kline, examined Betty Lou, and performed
several tests, including one where she turned off the ventilator
for several minutes. Betty Lou did not begin breathing. Dr. Kline
and the intensive care doctors met with Sally Suntori and her husband
Bill.
Dr. Kline began the family conference by saying gently, "I
am sorry, Mr. and Mrs. Suntori, but your mother is "brain dead".
There is no point in doing anything further, and we will be turning
off the ventilator." They continued to talk for another five
minutes answering the family's questions.
The family joined hands around Betty's bed, and Dr. Kline sat with
them as the ventilator was turned off. Betty took a few inefficient
breaths after the machine was stopped, but never really woke up.
The blood pressure and pulse both were unobtainable at five minutes.
John Jones hovered at death's door. In the last three months he
had had six major heart attacks. Due to his age and his Alzheimer's
disease he was not considered an appropriate candidate for a heart
transplant. Yet, here he was in the Intensive Care Unit once more,
again on a ventilator.
The cardiologist, Dr. Dirk Jensen had asked to meet with the family.
"Your father is only being maintained with these fancy machines.
As soon as we turn them off, he will stop breathing and die. Based
on the things that he told me before his dementia got so bad, I
would like to offer you an opportunity. If we just stop the machines
he will die now, and his organs will not be usable for anyone else.
But, if we coordinate our efforts carefully with the regional organ
bank, we can keep him going till we can take him to the operating
room. There we will turn off everything and wait for five minutes.
If he makes no attempt to breathe, a separate team of doctors will
immediately begin surgery to recover his liver, kidneys, and corneas
so that these will help other persons to live. We of course will
not be able to harvest his heart, as this is so damaged."
"So would you be killing our Dad to get his organs for those
other people?" asked Billy Jo, the daughter.
"I prefer to think that in fact we are unnecessarily prolonging
the inevitable, and given his dementia, it would not do him any
good to keep him around in this state. Besides, before his dementia
came on you know how concerned he was for people who use the dialysis
unit in Middle Fork. I think this is what he would want."
"I am so sorry," said Dr. Silcox to Tom and Sarah Waterford.
"Your daughter's heart disease is very serious and will only
get worse over time. I wish there was something else we could do
to help, but none of our medicines will really turn this thing around.
Our only hope is that we can find a suitable heart donor. With your
permission we will place her on the waiting list for heart transplant
right away."
Tom and Sarah were stunned. They somehow had not realized exactly
how severe Belinda's heart disease was. "You mean that the
only way Belinda can live is if someone else dies?" asked Sarah.
"We would be praying to our loving God that he would choose
to kill someone else so that Sarah would not have to die. And what
about the children further down the list? Would one of them die
because Belinda took a heart that might have been used to save them?"
Skin grafting, as a form of partial transplantation, probably
dates back to sixth century India, though it was not introduced
to Western medicine until the sixteenth century. Organ transplantation,
on the other hand, did not really come into practice till the1950s.
Initially performed in a few select sites, it has now become commonplace
throughout the free world, and in many places in the developing
world. Dr. James Dobson has encouraged his listeners on Focus on
the Family to volunteer to donate their organs in the event of their
death.
In 1968, Harvard Medical School published a report from a committee
chaired by Dr. H. K. Beecher, in the Journal of the American Medical
Association, defining brain death. This report was largely prompted
by the growing need for organs for transplantation and the feeling
that many usable organs were being lost for this purpose because
death was so vaguely defined. They defined brain death to be "permanent
non-functioning of the brain", and then spent the rest of their
report elaborating exactly what they meant by this.
Little major change has occurred in this definition in the past
thirty years. If no evidence of higher brain function is seen, and
if no evidence of cranial nerve function or brain stem activity
is discerned the patient is deemed "brain dead". Once
these criteria are satisfied, no further care is deemed necessary
or appropriate. Artificial ventilation may be discontinued at this
point without permission of the family, as the medical system is
not compelled to artificially ventilate a corpse.
The newer twist is the non-heart beating organ donor protocol (NHBODP),
which carries the transplant team a little further. In this scenario,
if death is imminent, the patient may be transported to the surgical
suite on life-sustaining machinery. The machines are then turned
off. When all signs of life cease, a five-minute waiting period
begins. If after the five minutes the organs are deemed salvageable,
the harvest of usable organs is performed.
A number of safeguards are built into the NHBODP to squelch overzealous
organ procurement, and to protect the donor and donor families from
unnecessary pain or invasion of privacy. Interestingly, while "Living
Will" and "Durable Power of Attorney for Health Care"
laws are in effect in most states, NHBODP rules are presently made
mainly on a local basis. Be that as it may, a question is raised:
"Do we actually know when death has occurred, and can it occur
in the presence of a yet-beating heart?"
The Bible does not directly say anything about these issues, but
perhaps some Biblical principles might apply to this discussion.
Let's look and see.
Scripture and Discussion Questions
Genesis 1:26,27; 2:21-23
Hebrews 9:27,28
Matthew 9:18-26
Matthew 22:23-33
John 20:1-8b
Acts 1:7-11
James 4:17
1) Does the fact that God created us, (as seen in Genesis chapters
1 and 2) have any bearing on our discussion of end-of-life issues?
Explain. If we took a naturalistic, evolutionary approach to human
life would this change our approach to end-of-life issues?
2) Hebrews chapter 9 talks about man dying once. Does this mean
that we are not to perform cardio-pulmonary resuscitation? Does
this mean that we are not to pursue organ transplantation to stave
off eventual inevitable death in those persons with diseased lungs,
kidneys or hearts?
3) In Matthew 9 Jesus intervenes and raises a dead child back to
life. Lazarus, the widow's son in Luke 7, and the widow's son in
1 Kings 17 are other examples of God's intervention to resurrect
from the dead. Does this mean that we should never "pull the
plug" because God may choose to intervene again?
4) If you were Dr. Kline in the first scenario, and Sally Suntori
told you that she was certain that God was going to intervene like
he did in the three stories above, how would you respond to her?
If she had no money to pay for the extended hospital stay would
this change your approach?
5) Scripture does not tell us a lot about our lives after the resurrection,
but it does clearly support the concept of a resurrection. Does
this have any bearing on your attitude about "brain death"
or NHBODP?
6) All four gospels discuss Christ's resurrection from the dead.
Many liberal scholars attempt to do away with the resurrection.
Does this really matter, since Jesus was such a great moral example
to us anyway? Does it have any impact on end-of-life discussions?
7) Acts 1 discusses Christ's ascension and his promised return.
Who cares? Why?
8) Read James 4:17 again. Does this imply that we are morally compelled
to give our bodies and the bodies of our loved ones for potential
organ donation? Why or why not? Have you signed an organ donor card?
Why or why not?
9) Why haven't Christian churches supported organ donor cards as
a way to help save lives and decrease pain and suffering for other
waiting on organ donor lists?
10) Christopher Reeves, the movie actor, would die quickly if anyone
were to turn his ventilator off. Does this mean his death is imminent?
If so, how does he differ from the persons discussed in the NHBODP?
11) How can we justify expensive intensive care in this country
when thousands die daily throughout the world from lack of food
and water?
12) Does the concept of not being yoked together with unbelievers
imply that a Christian should not designate an unbeliever as their
DPAHC?
Comments
1) "Vitalism" is the position that as long as there is
any sign of life we are morally obligated to do everything possible
to maintain life. Most Christian bioethicists do not hold to this
position. The Christian's view of eternal life differs markedly
from the rational secularist, and this difference does impinge on
this perspective.
2) Proper etiquette dictates that we let other have their serving
of cake first. If Tom and Sarah leave Belinda on the list someone
else may not get a heart, and die. On the other hand, do not Tom
and Sarah have primary responsibility to care for Belinda's needs?
Discuss.
3) The Non-Heart Beating Organ Donor Protocol discussed in today's
lesson is not a universal policy, but is developed on a local basis.
Check with your local hospital to see if they have a NHBODP, and
see if you can get a copy to review prior to the lesson.
4) Prior to the artificial ventilator, the issues raised in this
week's lesson did not exist. Many other issues are present now that
were not present fifty years ago. Discuss the importance of attempting
to base decision-making on biblical principles even when there are
no direct Bible passages to direct us.
5) Survey your class. How many have completed Durable Power of
Attorney for Healthcare documents or Living Will? How many have
specifically discussed end-of-life decisions with their spouse or
families? Ask all people present to consider these possibilities.
6) Simple Durable Power of Attorney for Healthcare and Living Will
documents can be downloaded from the internet, or obtained from
your neighborhood library, or from your local hospital. See if you
can find an example to bring to class.
7) Dr. Jensen, in the second vignette, actually approached the
family about the specifics of obtaining Mr. Jones's organs. Usually
hospital protocols are set up to keep the treating physician's role
completely separate from that of the procuring physician, so there
will be no conflict of interest and the patient will always receive
the doctor's undivided attention.
8) In the United Kingdom age is used as a strict criteria for allocation
of resources. In the U. S. A. we are extending expensive health
services to older and older people. There are pros and cons to both
positions. This might prompt an active discussion.
PRAYER REQUESTS: As you close today's
lesson together, pray that God will help you continue to think about
these difficult questions in the week ahead. Do you need to sign
an organ donor card as an act of Godly generosity to those you leave
behind? Ask God to help you prayerfully consider this issue this
week.
For Further Reading:
An excellent resource on these issues may be obtained through a
special request at your library-probably through an inter-library
loan. This out-of-print book, considered a bioethics classic is
by Paul Ramsey, The Patient as Person-Explorations in Medical Ethics
(New Haven, Connecticut: Yale University Press, 1970). Chapter two
deals with redefining death, and chapters four, five and six deal
with specific aspects of organ transplantation.
American Medical Association updates its Code of Medical Ethics-Current
Opinion with Annotations (Chicago, Illinois: American Medical Association,
1997) every year or two. Chapter 2.00 covers opinions on social
policy issues, including each of the ten chapter issues covered
in this curriculum. In addition to its policy statements, it contains
the AMA Principles of Medical Ethics, and Fundamental Elements of
the Patient-Physician Relationship.
Judith C. Ahronheim, Jonathan Moreno and Connie Zuckerman, Ethics
in Clinical Practice (Boston, Massachusetts: Little Brown and Company,
1994). Written collaboratively by a physician, a philosopher and
an attorney, the bulk of this volume is case studies. Case 11 "A
religious objection to the determination of brain death" discusses
conservative Jewish religious objections to the concept of brain
death. (Several states now recognize the right for a family to claim
this religious exemption.)
Terrence F. Ackerman and Carson Strong, A Casebook of Medical Ethics,
(New York: Oxford University Press, 1989). Casuistry is the discipline
of analyzing deriving ethical principles from the throes of actual
cases. This is a good example of a secular casuistry model for exploring
bioethics. Case 2.8 is entitled "Conflict about Maintaining
a Brain-Dead Woman for the Sake of her Fetus."
Robert Orr, M.D., David Biebel, D. Min., and David Schiedermayer,
M.D., More Life and Death Decisions, (Grand Rapids, Michigan: Baker
Books, 1990). Several chapters in this book deal with tough end-of-life
decisions. Pages 102-103, "Definition of Death" discusses
brain death in an easily understandable fashion.
Franklin E. Payne, Jr., M.D., Biblical Healing for Modern Medicine,
(Augusta, Georgia: Covenant Books, 1993). Dr. Payne often has a
slightly different angle on issues that other thinkers. Pages 97-99,
"Brain Death and Organ Transplantation," provide an example
of his unique perspective.
|
