Brain Death: Do We Know Enough?

 

The following is my article published in the National Catholic Bioethics Quarterly (Spring 2016): 55-59. © 2016 The National Catholic Bioethics Center Quarterly.

Abstract. Every year, people make decisions based on trust in the certainty of diagnoses of brain death. These decisions range from signing an organ donation card to withdrawing life support from a loved one. Two recent developments have revived concerns about medical standards for determining brain death. One is a recent study on variability in brain death policies in the United States; the other is the filing of a federal lawsuit to rescind the death certificate of Jahi McMath, a teenager who appears to have survived a 2013 declaration of brain death. The author examines these developments and asks whether trust in the certainty of brain-death determinations is currently warranted.

Nancy Valko, RN, ALNC, is a legal nurse consultant and a spokesperson for the National Association of Prolife Nurses. A registered nurse since 1969, she has worked mostly in critical care as well as hospice, oncology, and home health. She is a past co-chair of the St. Louis Archdiocesan Respect Life Committee. She received the People of Life award from the US Conference of Catholic Bishops in 2015.

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Two recent developments on the controversial issue of brain death have revived concerns about the medical standards currently used for determining brain death. One was the publication of a JAMA Neurology study of 508 US hospitals, titled “Variability of Brain Death Policies in the United States,” by Dr. David Greer et al., which found major variations in their policies for determining brain death. The study concluded that “hospitals should be encouraged to implement the 2010 AAN [American Academy of Neurology] guidelines to ensure 100% accurate and appropriate determination of brain death.”1

The other development surrounds a federal lawsuit pushing to rescind the death certificate of Jahi McMath. McMath, a teenager from Oakland, California, was declared brain dead two years ago but is apparently still surviving and may be showing some signs of improvement.2

Every year, people make decisions—to withdraw life support from loved ones or to sign organ donation cards—based on trust in the certainty of a diagnosis of brain death. Is such trust warranted?

A Short History of US Brain-Death Policies

Although the concept of irreversible coma was first introduced in 1959, the cur- rent legal and medical concept of brain death gained widespread acceptance after the publication, in 1968, of “A Definition of Irreversible Coma,” the report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death.

The stated purpose of the Harvard report was “to define irreversible coma as a new criterion for death,” because new technology such as ventilators could maintain a patient “whose heart continues to beat but whose brain is irreversibly damaged.” The committee noted that “obsolete criteria for the definition of death can lead to controversy in obtaining organs for transplantation.” The Harvard paper laid out four conditions for a diagnosis of brain death: (1) unreceptivity and unresponsitivity, (2) no movement or breathing, (3) no reflexes, and (4) a flat electroencephalogram, providing confirmatory data that should be utilized “when available.”3

Starting in the early 1970s, various state legislatures and courts acted to turn brain death into a legally recognized standard for determining death by loss of all brain function. Patients declared brain dead could then be removed from life support measures, like mechanical ventilation, without legal ramifications or their organs could be harvested while their hearts were still beating and a ventilator kept their lungs functioning.

In 1981, the US Uniform Determination of Death Act formally added “irreversible cessation of all functions of the entire brain, including the brain stem” to the legal definition of death.4 However, while the act set the general legal standard for determining brain death, it did not dictate the medical criteria. Many state laws  just cite “accepted medical standards” for determining brain death. Over the years, efforts were made to standardize these medical criteria, most recently by the AAN guidelines established in 2010.5

Not All Hospitals Comply with the Guidelines

In an interview with Medscape, David Greer, the lead author of the study in JAMA Neurology, expresses concern that not all of the 508 US hospitals surveyed were “100% compliant” with the 2010 guidelines by the American Academy of Neurology. Of the hospitals surveyed, the Medscape article notes that only “about a third of policies (33.1%) required specialist expertise in neurology or neurosurgery, but 150 policies had no mention of who could perform the determination.” 6 The article also notes that not all hospital policies require testing of lower brainstem function to establish the loss of all brain function, and not all comply with other AAN recommendations such as establishing the cause of the brain dysfunction, the absence of effects of specific medications like sedatives, and crucial aspects of the apnea test.

One of the potentially disastrous consequences of these inconsistencies in hospital testing policies is that a person can be treated as a living patient at one hospital but declared brain dead at another.

Would full compliance with the 2010 guidelines “ensure 100% accurate and appropriate determination of brain death”? Probably not, given the findings of the 2010 report updating the AAN guidelines.7 Eelco Wijdicks et al. observe that “many of the details of the clinical neurologic examination to determine brain death can- not be established by evidence-based methods. The detailed brain-death evaluation protocol that follows is intended as a useful tool for clinicians. It must be emphasized that this guidance is opinion-based. Alternative protocols may be equally informative.” They also note that there is “insufficient evidence” to determine such crucial standards as “the minimally acceptable observation period to ensure that neurologic functions have ceased irreversibly,” “the comparative safety of techniques used for apnea testing,” and the accuracy of “newer ancillary tests [in confirming] the cessation of function of the entire brain.”8

The significance of these criteria is highlighted in a 2012 article, “A Survey of American Neurologists about Brain Death: Understanding the Conceptual Basis and Diagnostic Tests for Brain Death,” by Ari Joffe et al.9 The authors note, “It has been shown that some brain functions continue after accurately clinically diagnosed BD (brain death), including EEG activity in 20%, evoked potential activity in 5%, and hypothalamic neuroendocrine function in > 50%. These activities may be explained by the finding that continued brain blood flow occurs in 5–40% of BD patients, and pathologic destruction of brain does not occur in more than 40% of BD patients (even after over 24–48 hr. of maintained circulation).”10 Thus there seems to be reasonable cause for concern whether even 100 percent compliance with AAN guidelines would completely ensure the accuracy of a diagnosis of brain death or the validity of some critical brain-death tests.

Jahi McMath

In December 2013, thirteen-year-old Jahi McMath suffered cardiac arrest after undergoing surgery for sleep apnea at Children’s Hospital Oakland, in California. Although doctors managed to resuscitate her, they declared McMath brain dead and prepared to remove the ventilator. Hoping she might recover, however, the family insisted that it remain in place.

After several court battles, a judge permitted McMath’s family to transfer her to a facility in New Jersey that allowed the continued use of the ventilator. Two years later, McMath’s family is still fighting, suing in federal court have her death certificate rescinded.11 According to the family’s attorneys, “Jahi does not fulfill California’s statutory definition of death, which requires the irreversible absence of all brain function, because she exhibits hypothalamic function and intermittent responsiveness to verbal commands.” 12

A ruling to rescind McMath’s death certificate would have profound implications for the medical and legal determination of brain death, especially since her initial diagnosis was confirmed by multiple doctors in a well-respected hospital.

McMath is not the first person to survive for a prolonged time after a brain- death diagnosis. Alan Shewmon, MD, studied approximately 175 cases of long-term survival after a declaration of brain death, for periods ranging from one week to more than fourteen years.13 In other cases, pregnant women declared brain dead have been able to gestate unborn babies for weeks or months until a healthy delivery.14

Most concerning of all are cases like that of Zach Dunlap, a young man from Oklahoma who was declared brain dead after an all-terrain vehicle accident in 2008. Testing showed no blood flow to his brain, and Dunlap was being considered for organ donation when a relative discovered a physical response from Zach. Four months later and already making plans to return to work, Dunlap appeared on NBC’s Today show, where he told hosts that he heard a doctor say he was dead, and it “just made me mad inside.”15

Alarmingly, there have been other reported “near misses” like Dunlap’s that also did not lead to rigorous medical investigations to determine what went wrong with the initial brain-death determinations. Yet experts continue to maintain that there is “no documented report of patients regaining brain function after being declared brain dead,” although some allow that “maybe mistakes happened and they weren’t reported.”16

Persistent Controversies

Controversy about brain death has simmered for years in bioethical and medical circles. Influential  experts such as Robert Truog and Franklin Miller argue that doctors should drop the rule requiring that people be declared dead before vital organs are taken, and instead merely obtain “valid informed consent for organ donation from patients or surrogates before the withdrawal of life-sustaining treatment in situations of devastating and irreversible neurologic injury.”17

The Catholic Church has been involved in the controversy over brain death since the Harvard report cited Pope Pius XII’s 1957 address “The Prolongation of Life” to support its recommendations.18 Since then, there have been several papal statements and conferences on the determination of brain death. Collectively, these are widely seen to indicate a cautious acceptance of the concept of brain death that is based on the assurance of medical certainty to provide moral certainty.

When the issue is death, medical ethics must be backed up by accurate medical facts. In the case of the legal and medical definition  of brain death as “irreversible cessation of all functions of the entire brain, including the brain stem,”19 medical science, not philosophical speculation, must provide the proof beyond a reasonable doubt.

When cases like those of McMath and Dunlap are routinely dismissed instead of rigorously investigated to establish the facts, medical certainty is not achieved and medical integrity is undermined. In addition, when hospitals set their own standards and policies for determining brain death without external accountability, lives—as well as the essential and necessary trust in the health care system—can and possibly will be lost.

Footnotes:

1. David M. Greer et , “Variability of Brain Death Policies in the United States,” JAMA Neurology 73.2 (February 1, 2016): 213, doi: 10.1001/jamaneurol.2015.3943.3943. The updated AAN guidelines are presented in Eelco F. M. Wijdicks et al., “Evidence-Based Guideline Update: Determining Brain Death in Adults—Report of the Quality Standards Subcommittee of the American Academy of Neurology,” Neurology 74.23 (June 8, 2010): 1911–1918.

2. McMath et v. State of California et al., no. 4:2015cv06042 (N.D. Cal. Dec. 23, 2015); see David DeBolt and Malaika Fraley, “Jahi McMath: Family Sues in Federal Court to Have Brain-Dead Girl Declared Alive,” Mercury News, December 24, 2015, http://www.mercurynews.com/.

3. Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death, “A Definition of Irreversible Coma,” JAMA 6 (August 5, 1968): 337, doi: 10.1001/jama.205.6.337. P. Mollaret and M Goulon identified irreversible coma in their essay “Le Coma Dépassé (memoire preliminaire),” Revue Neurologique 101.1 (July 1959): 3–15.

4.National Conference of Commissioners on Uniform State Laws, Uniform Determination of Death Act, approved 1980/1981, http://www.uniformlaws.org/.

5. Allison Gandey, “New Brain Death Guidelines Issued,” com, June 10, 2010, http://www.medscape.com/.

6. Pauline Anderson, “Not All Hospital Brain Death Policies Comply with Guidelines,” com, December 30, 2015, http://www.medscape.com/, emphasis added.

7. Wijdicks et al , “Evidence-Based Guideline Update.”

8. Ibid. 1911, 1914, emphasis added.

9. Ari Joffe et , “A Survey of American Neurologists about Brain Death: Understanding the Conceptual Basis and Diagnostic Tests for Brain Death,” Annals of Intensive Care 2.1 (February 17, 2012): 1–8, doi: 10.1186/2110-5820-2-4.

10. Ibid, 4

11. DeBolt and Fraley, “Jahi McMath”

12. Winkfield v. Children’s Hospital Oakland, no. RG-15760730, first amended com plaint (CA, Ct. Alameda County, Nov. 4, 2015), para. 36, original emphasis.

13. Alan Shewmon, “Chronic ‘Brain Death’: Meta-Analysis and Conceptual Con- sequences,” Neurology 51.6 (December 1998): 1538–1545.

14. Majid Esmaeilzadeh et , “One Life Ends, Another Begins: Management of a Brain-Dead Pregnant Mother—A Systematic Review,” BMC Medicine 8.74 (November 18, 2010): doi: 10.1186/1741-7015-8-74.

15. Natalie Morales, “‘Dead’ Man Recovering after ATV Accident,” NBC News, March 24, 2008, nbcnews.com/.

16. Pauline Anderson, “Not All Hospital Policies ”

17. Robert Truog and Franklin G. Miller, “The Dead Donor Rule and Organ Transplantation,” New England Journal of Medicine 359.7 (August 14, 2008): 675, doi: 10.1056/NEJMp0804474.

18. Ad Hoc Committee of Harvard Medical School, “Definition of Irreversible Coma,” 88 note 1, citing Pius XII, “The Prolongation of Life,” Address to an International Congress of Anesthesiologists (November 24, 1957), The Pope Speaks 4 (Spring 1958): 393–398.

19. Commissioners on Uniform State Laws, “Uniform Determination of Death Act,” sec 1.

“Everybody’s a Winner When Euthanasia Combines with Organ Donation, Say Doctors”

This excellent article by Michael Cook  titled “Everybody’s a Winner When Euthanasia Combines with Organ Donation, Says Doctors” is a must read for anyone concerned about ethics and healthcare.

Michael Cook, the current editor of Mercatornet, writes that

Several Dutch and Belgian doctors have proposed legal reforms to increase the popularity of combining euthanasia and organ donation in the Netherlands and Belgium.

Writing in the Journal of Medical Ethics, they report valuable unpublished information about the prevalence of the procedure. So far, it has been performed only about 40 times in the two countries. However, there is “a persisting discrepancy between the number of organ donors and the number of patients on the waiting lists for transplantation” – which euthanasia patients could help to balance. (Emphasis added)

Ominously, the authors of this British Medical Journal article  titled “Legal and ethical aspects of organ donation after euthanasia in Belgium and the Netherlands”, write that public perception of this formerly abhorrent practice is increasingly positive:

“transplant coordinators in Belgium and the Netherlands notice a contemporary trend towards an increasing willingness and motivation to undergo euthanasia and to subsequently donate organs as well, supported by the increasing number of publications in popular media on this topic.

and

“In the context of organ donation after euthanasia, the right of self-determination is a paramount ethical and legal aspect. It is the patient’s wish and right to die in a dignified way, and likewise his wish to donate his organs is expressed. Organ donation after euthanasia enables those who do not wish to remain alive to prolong the lives of those who do, and also—compared with ‘classical’ donation after circulatory death—allows many more people to fulfil their wish to donate organs after death.” (Emphasis added)

This slippery slope actually started in 1998 when Jack Kevorkian removed the kidneys of one of his victims and offered them for transplantation. Almost everyone was stunned and horrified. Transplant surgeons refused the organs at that time but the reasons given in some news articles unfortunately had less to do with the ethics than with the concerns over the viability of the organs and the  harvesting technique of the organs themselves.

By 2003, the prestigious journal Critical Care Medicine published an article titled “Role of brain death and the dead-donor rule in the ethics of organ transplantation” by Drs. Robert D. Troug and Walter M. Robinson that went even further:

“We propose that individuals who desire to donate their organs and who are either neurologically devastated or imminently dying should be allowed to donate their organs, without first being declared dead”.  (Emphasis added)

Thus, the actual cause of death would be the organ removal which, in itself, would be euthanasia.

We should not assume that legalized organ donation euthanasia can’t happen here in the US when the public has already been softened up for years by a mostly sympathetic media publicizing sad cases like Brittany Maynard’s and the relentless Compassion and Choices campaign to legalize physician-assisted suicide in every US state.

I can even envision a time when organ donation euthanasia could be presented to the public as merely “medically assisted death-with benefits.”

 

 

A Belated But Wonderful Christmas Present

Last December, I wrote a blog “All I want for Christmas is…a kidney” about Bernie, my daughter-in-law, and her need for a kidney transplant. Last Friday, she received one!

Bernie is doing well and should be home sometime this week. It will be a new life for her and my son Steve without the hours of dialysis, strict dietary restrictions and other limitations. Their faith, hope, patience and acceptance of their situation have been truly inspiring!

Unfortunately, Bernie’s wonderful father Gene Buerke did not live to see this day. He died from a massive stroke 2 weeks ago but we are sure he is celebrating in heaven. Please pray for the repose of his soul as well as Bernie’s speedy recovery.

Thank you all for your prayers and support!

 

Do We Know Enough About Brain Death?

Just last month, there were two major developments reported on the controversial issue of brain death. One was an article about a lawsuit to revoke the death certificate of Jahi McMath, a California teenager who was declared brain dead 2 years ago but is still alive and apparently showing some signs of improvement.

The other was a December 30, 2015 article in Medscape, a website for medical professionals that requires subscription, titled “Not All Hospital Brain Death Policies Comply With Guidelines” . The article reports on a medical journal study titled “Variability of Brain Death Policies in the United States.”

Jahi McMath

Jahi McMath, a 13-year-old girl, underwent a routine surgery for sleep apnea in December 2013 at a California children’s hospital. That night she started bleeding and eventually her heart stopped. Her heart was restarted and she was placed on a ventilator to stabilize her condition, but soon the doctors declared her brain dead and prepared to remove the ventilator. However, the family insisted that the ventilator be continued, hoping that Jahi might eventually get better.

The doctors disagreed, insisting that Jahi was legally dead by brain death criteria. The parents went to court to keep the doctors from removing her ventilator but after a series of legal battles lasting weeks, a judge eventually gave Jahi’s family permission to transfer her to another facility that would continue the ventilator.

Virtually all the ethicists and other experts contacted by most media outlets condemned the family’s actions as denying the reality of brain death. In a January 10, 2014 USA Today article, ethicist Arthur Caplan, head of the bioethics division at New York University’s Langone Medical Center, criticized the judge’s decision for Jahi’s family, declaring that Jahi’s new doctors are “trying to ventilate and otherwise treat a corpse,” Caplan said. “She is going to start to decompose.”

Now, 2 years after Jahi was declared brain dead, her family is in federal court suing to revoke her death certificate because as their experts contend

“At this time, Jahi does not fulfill California’s statutory definition of death, which requires the irreversible absence of all brain function, because she exhibits hypothalamic function and intermittent responsiveness to verbal commands.”

A future ruling revoking Ms. McMath’s death certificate would be groundbreaking.

“Variability of Brain Death Policies in the United States.”

In this December 28, 2013 Journal of the American Medical Association Neurology article, a study was done of 508 US hospital policies on brain death determination.

Alarmingly, the article states that hospital brain death criteria requirements “are not 100% compliant” even with updated 2010 guidelines by the American Academy of Neurology which require only one examination to determine brain death.

And of the total 508 hospitals, the article states that only

“about a third of policies (33.1%) required specialist expertise in neurology or neurosurgery, but 150 policies had no mention of who could perform the determination. Many policies still allow for more junior physicians to determine brain death, the authors noted.” (Emphasis added)

Also disturbing, the article noted that some policies didn’t require testing of lower brainstem function (required for a finding of irreversible loss of all brain functions) with less than 80% of the policies requiring the absence of a cough reflex. Only 57.2% of hospital brain death policies required that oxygen be given to maintain oxygenation during the critical apnea test to determine if a patient can take breaths off a ventilator, even though low a low oxygen level can lead to more brain damage.

In an effort to reassure, Gene Sung, MD, past-president, Neurocritical Care Society, and director, Division of Neurocritical Care and Stroke at UCLA claims that he

agreed that there have there have been no documented reports of regaining function after a declaration of brain death. “But still, we don’t know for sure; maybe mistakes happened and they weren’t reported,” he said. (Emphasis added)

Actually, there have been multiple reported cases of people regaining at least some function after a brain death declaration such as Zach Dunlap (who fully recovered) as well as Jahi McMath.

If as Dr Greer, the lead author of the study, states “This is one of those diagnoses where we need to be correct 100% of the time”, must we not rigorously examine such cases to determine if or why there was a misdiagnosis to ensure that current brain death guidelines really hold up to scrutiny?

Besides the potential premature loss of lives, our medical integrity is at stake and we medical professionals must prove worthy of the trust society gives us.

All I Want For Christmas Is…..A Kidney

All I want for Christmas is a kidney but not for me. I want it for my wonderful daughter-in-law Bernie, short for Bernadette.

Bernie Valko had a kidney transplant when she was 15 years old after a birth complication damaged her kidneys and almost cost her life. For almost 17 years, Bernie did well with her new kidney, went to college and became an occupational therapist.

In September 2012, Bernie was set to marry my son Steve when her transplanted kidney failed the night before their wedding. Bernie told my son that, under the circumstances, they could cancel the wedding. Instead my son said his only regret was not marrying her sooner! No one knew before the wedding except family members. Nevertheless, Steve and Bernie’s wedding was a joyous occasion, although their honeymoon had to be postponed indefinitely.

Three days later, Bernie became very ill and was hospitalized. Dialysis was finally started but difficulties arose. Despite this, Bernie kept working as much as possible. Currently, she has dialysis 3 days a week and works three days a week. As a former dialysis nurse myself, I know that most dialysis patients are unable to work. However, Bernie is a trooper and even volunteers at their St. Louis, Mo. parish.

Bernie desperately needs a transplant. She needs a donor with an O+ blood type for a living donor transplant because such kidneys last almost twice as long and avoid the ethical concerns with other transplants.

Becoming a living kidney donor is not a decision to be made lightly. Information on becoming a living kidney donor is online at http://www.barnesjewish.org/become-a-kidney-transplant-living-donor . Bernie is now at the top of the Barnes Jewish Hospital waiting list.

In the meantime, Bernie and Steve also started a Facebook page “Find a Kidney for Bernie” with pictures and contact information if you or someone you know with an O+ blood type would like to be tested for a living kidney donation to Bernie.

Medical Professionals, Planned Parenthood and Fetal Tissue from Aborted Babies

On August 6, 2015, the Medscape website for medical professionals had an article: “Reader Poll: “Should Medical Societies Support Federal Funding for Planned Parenthood?” with 3 questions:

1. Do you agree that Planned Parenthood should continue to receive federal funds for non-abortion-related care?
2. Do you believe that these 18 medical societies were justified in stating their support for Planned Parenthood?
3. Do you believe that it is ethical for Planned Parenthood to donate aborted fetal tissue for use in medical research?

Not surprisingly, given how these questions are worded, a large majority voted yes.

The Medscape article referenced a letter to Congress dated 8/3/2015 by 18 medical societies supporting continued funding for Planned Parenthood.
However, when I accessed the letter, it surprisingly says nothing about fetal tissue research.

I am including the actual letter and its signers below.

I wonder if these groups’ members feel the same way. I checked on two groups and couldn’t find the letter on the American Congress of Obstetricians and Gynecologists or Society’s for Adolescent Health and Medicine’s websites.

I would encourage members of these groups as well as other ethical doctors and nurses to contact to contact these organizations to encourage them to protest this position (and the use of aborted babies for fetal tissue research), especially since it appears that many medical professionals are unaware of the issues involved.

I have seen this before.

Even though the American Nurses Association did not sign this letter and a current search shows no position on Planned Parenthood or fetal tissue use on its website, I was a member of the American Nurses Association (ANA) years ago and tried to work within that organization at a state level on several ethical issues. I read every issue of ANA’s Journal of Nursing, particularly the political section. When the ban on partial birth abortion came up in Congress, I read nothing about it in the Journal.

Awhile later, I was watching a political talk show and one of the panelists mentioned that the ANA was against the ban. That was news to me so I searched for the information on the internet. It took some time but I finally found the letter.

I tracked down the public relations director of the ANA and called her. At first, she said that she didn’t know what I was talking about but eventually found the information herself and seemed surprised.

I told her that I no longer could be a member of ANA not only because of its’ stance on partial birth abortion but also because of the secrecy. We members were not polled or even informed. I also told her that I would encourage other ANA members to also leave if the ANA did not change its position or inform its membership.

The PR person apologized. I gave her my phone number and encouraged her to have someone from the ANA contact me.

I never heard back from them.

We need accountability from our professional organizations, especially since these organizations claim to represent the interests of groups of medical professionals.

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In a letter dated August 3, a group of 18 medical societies, including the American Congress of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, ask the Senate and House leadership to continue to allow Planned Parenthood to participate in federal health programs.

https://filemanager.capwiz.com/filemanager/file-mgr/acog/Provider_Ltr_in_Support_of_Planned_Parenthood_Funding_Updated.pdf

August 3, 2015

The Honorable Mitch McConnell
Senate Majority Leader
S-230, U.S. Capitol Building
Washington, DC 20510
The Honorable John Boehner
Speaker of the House of Representatives
H-232, U.S. Capitol Building
Washington, DC 20515
Dear Leader McConnell and Speaker Boehner:

As organizations representing health care professionals and the people they serve across the country, we strongly oppose any effort to prevent Planned Parenthood health centers from participating in federal health programs, including Medicaid and the Title X family planning program. Any proposal to exclude Planned Parenthood from public health programs will severely curtail women’s access to essential health care services, including family planning, well-woman exams, breast and cervical cancers screenings, and HIV testing and counseling. At a time when we should be focused on improving the health of all people, it is frustrating to witness ongoing attempts to cut off access to life-saving preventive care.
Planned Parenthood health centers play a crucial role in improving the health and lives of people across the country. In fact, 2.7 million people rely on Planned Parenthood for health care. For many women, Planned Parenthood is their only source of care—offering basic preventive services that are fundamental to women’s health and well-being. Each year, Planned Parenthood health centers provide nearly 400,000 cervical cancer screenings and nearly 500,000 breast exams.

Additionally, Planned Parenthood provides over 2.1 million contraceptive services and nearly 4.5 million tests and treatments for sexually transmitted infections, including HIV. These services improve women’s health, prevent an estimated 516,000 unintended pregnancies, and decrease infant mortality.
Policies that would exclude Planned Parenthood from public health funding would hurt millions of women and undermine health care access in communities across the country. Approximately 60 percent of Planned Parenthood patients access care through Medicaid and Title X, in addition to those who rely on other essential programs, including maternal and child health programs and Centers for Disease and Prevention (CDC) breast and cervical cancer screening programs.

In some states, Planned Parenthood is the only provider participating in Title X, and more than 50 percent of Planned Parenthood health centers are located in a medically underserved or health professional shortage area. Because federal law already requires health care providers to demonstrate that no federal funds are used for abortion, prohibitions on funding for preventive care at Planned Parenthood health centers will only devastate access to these life-saving services.

Every day, we see the harmful impact that unequal access to health care has on women and communities across the country, and we therefore strongly support policies that improve access to affordable, quality health care. Policies that would deny Planned Parenthood public health funds only serve to cut millions off from critical preventive care, and we strongly oppose any effort to do so. Should you have any questions, please contact ACOG Government Affairs staff, Rachel Gandell at 202-863-2534 or rgandell@acog.org.

Sincerely,

American College of Nurse-Midwives
American Congress of Obstetrician and Gynecologists
American Medical Women’s Association
American Medical Student Association
American Public Health Association
American Society for Reproductive Medicine
Association of Reproductive Health Professionals
Association of Women’s Health, Obstetric and Neonatal Nurses
Doctors for America
GLMA: Health Professionals Advancing LGBT Equality
National Alliance to Advance Adolescent Health
National Association of Nurse Practitioners in Women’s Health
National Family Planning and Reproductive Health Association
National Hispanic Medical Association
National Physicians Alliance
Physicians for Reproductive Health
Society for Adolescent Health and Medicine
Society for Maternal-Fetal Medicine
cc: Senate Minority Leader Harry Reid
House Minority Leader Nancy Pelosi

Killing to Heal? Ethical Problems with DCD (Donation after Circulatory Death)

This first appeared as an item in the Pro-Life Wisconsin Monday Update, 7-13-15. It is a short overview of ethical concerns about DCD (donation after cardiac or circulatory death and formerly called NHBD, non-heart beating donation).

Killing to Heal? Ethical Problems with DCD (Donation after Circulatory Death)

By Nancy Valko, RN, ALNC and Julie Grimstad, Patient Advocate, Prolife Healthcare Alliance

Donation after Circulatory Death (DCD) is ethically controversial because it links the so-called “right to die” with organ donation, opening a terrible Pandora’s Box. In the quest to secure life-saving vital organs, DCD is pushing the boundaries of what constitutes death. Those with the responsibility to determine death are cautioned to take ample time, even in hospice patients, lest death be declared prematurely. When death is hastily declared for the purpose of acquiring organs, as the DCD procedure requires, the paramount ethical principle – the sanctity of human life – can be overridden by utilitarian calculations of whose life is worth more, the organ donor’s or the recipient’s. Consider the following:
1. DCD involves taking organs from patients who have not been determined to be “brain dead” but who are on ventilators and considered hopeless in terms of predicted survival or “quality of life.” U.S. guidelines (from The Organ Procurement and Transplant Network) even allow conscious disabled people on ventilators to agree to the DCD procedure. In spite of the fact that the patient’s or family’s consent to removal of the ventilator must precede consent to organ donation, these guidelines imply that disabled patients’ organs are more valuable than their lives.

2. As noted by reporter David Wahlberg, “…critics, including some Catholic hospitals and the disability rights group Not Dead Yet, say circulatory death donation can pressure families to withdraw life support. Some say drugs given beforehand can hasten death.” [“UW Hospital a leader in alternative to brain death organ donation,” David Wahlberg, Wisconsin State Journal, July 5, 2015]

3. The DCD procedure requires a doctor’s prediction that a person’s heartbeat and breathing will stop within 1-2 hours after the ventilator is removed, but doctors are often wrong. A study presented at the 2015 Transplant Congress by University of Wisconsin doctors stated, “In 46 patients (27.2%) no organs were recovered because the patients did not expire within 2 hours.” Such patients are then just returned to their rooms to die without further treatment. There is something dangerously awry when doctors’ prognoses are so often wrong – fatally wrong.

4. The DCD procedure usually involves moving the patient-donor to an operating room and there removing the ventilator in order to bring about death in a controlled environment. The donor’s organs are taken only 2-5 minutes after breathing and heartbeat stop. Haste saves organs because they rapidly deteriorate without circulation.

5. The basic ethical principle guiding organ donation is the Dead Donor Rule: a person must be dead before the removal of organs for transplantation. Shouldn’t we be absolutely certain a person is dead before organs necessary for life are removed from him/her? What good is the Dead Donor Rule if the “dead” part is fiction?

6. Evidence suggests at least some DCD donors would survive and even recover given time and therapy. For example, NBC’s Today show, September 6, 2011, featured an interview with Shelli Eldredge, a young mother who was comatose after a traumatic brain injury from an accident on June 16, 2011. A doctor recommended stopping life support. Although Shelli’s husband, a doctor himself, also believed it was medically impossible for her to recover, he wouldn’t give up. After a month, Mrs. Eldredge woke up and started speaking. Three months later, she was giving this interview – alert, articulate, and working toward a full recovery.

A civilized society must not allow the deaths of some people to be manipulated in order to obtain organs for others.

Our Grandson Was Saved By An Adult Stem Cell Transplant

Wednesday, July 1, 2015, our 2 year old grandson Liam and his family were featured on the local news by the St. Louis NBC affiliate. The video segment titled “St. Louis family meets life-saving bone marrow donor” is now online at:
http://www.ksdk.com/story/news/local/outreach/2015/06/30/bone-marrow-transplant-donor-reunion/29537057/ and it is wonderful.

It told the basic story about how our 2 year old grandson Liam Bryant, who like his deceased older brother Noah, had a bone marrow transplant for a rare autoimmune disease called HLH and is doing well thanks to the generosity of a stranger named Kevin who donated his bone marrow. There were many tears of joy when Liam and the family were able to meet Kevin in person.

But there is much more to the story.

There are two types of stem cell procedures. Ethically controversial embryonic stem cell (ESC) procedures and non-controversial adult stem cell procedures. ESC procedures are controversial because the cells used are derived from human embryos – babies at a very early stage of development – who are killed in the process. ESC procedures, so far, have not proved to be the breakthrough they were expected to be.

Liam’s transplant came from adult stem cells. Adult stems cells are now proving very useful in the treatment of many diseases thanks to ongoing research, but bone marrow transplants using adult stem cells have been successful for decades.

Liam’s Parents Also Chose Life

The autoimmune disease HLH is notoriously difficult to diagnose and there is only a short window of opportunity to successfully treat the disease with a bone marrow transplant. Liam’s 6 year old brother Noah’s HLH was not diagnosed early and although he fought hard for many months, complications of his bone marrow transplant took his life in October 2012.

While we were all standing vigil for Noah two days before he finally died, Noah’s parents received the difficult news that a special prenatal test showed that Liam, Noah’s unborn brother, also had HLH. The abortion option was brought up. This happened even though little Liam himself would have an excellent chance for a bone marrow transplant cure, especially since his bone marrow transplant could be planned before he showed any sign of the disease.

I was so proud of my stepdaughter when she instantly replied to the abortion “option” with outrage. She told the doctor that it was unthinkable that she would be offered the “choice” of killing one of her children while watching another one of her children die!

The “helpful” doctor who suggested abortion probably thought that she was only being sympathetic, but, like too many people in our society, she saw abortion as an acceptable solution to a tough situation. My stepdaughter enlightened the doctor not only about the truth of abortion as killing but also about the effects on the family. So-called “therapeutic” abortion is never therapeutic for either the child or the family. How can killing a child ever prevent grief and guilt? How can anyone rationalize the very real difference between dying and being killed?

BONE MARROW AND ORGAN DONATION

As I have previously written (see my previous blogs on Non-brain Death Organ donation, Parts one and two), many people are understandably concerned about signing an organ donation card because of the controversies surrounding brain death organ donation and DCD (donation after circulatory death).

However, there are alternatives such as the donation of bone marrow, blood or even a kidney or part of a liver while still alive and healthy. In addition, after death, tissues like bone or corneas can be taken even hours after death is certain.

HOW TO BECOME A BONE MARROW DONOR FOR SOMEONE LIKE OUR GRANDSON

If you or someone you know is between the ages of 18 and 44 and wants to consider being tested for bone marrow donation, you can get more information and join the bone marrow registry at Be The Match at https://bethematch.org/Support-the-Cause/Donate-bone-marrow/Join-the-marrow-registry/

Bone marrow donation can be done by a technique that collects peripheral blood stem cells (PBSC) from the donor’s blood as well as by having bone marrow taken from the hip as Liam’s donor did. An explanation of both donation methods can be found at >https://bethematch.org/transplant-basics/how-marrow-donation-works/steps-of-bone-marrow-or-pbsc-donation/

We will continue to be eternally grateful to Liam’s donor for a true gift of life.

Addendum from the Pro-Life Healthcare Alliance Newsletter July 23, 2015 :

There is a third designation of stem cells that is little known but is gaining momentum: the fetal stem cell. Human beings are called embryos for the first eight weeks after fertilization. After that, we enter the fetal stage, which is from nine weeks post-fertilization until birth. Fetal stem cells are stem cells harvested during the fetal stage of development. Fetal stem cells, often procured from elective abortions, are disingenuously classified as “adult” stem cells simply because they do not come from embryos. Needless to say, this creates great confusion. Be wary. See: https://www.ncregister.com/daily-news/stem-cell-stealth-mode-when-terminology-masks-immorality/

Non-Brain Death Organ Donation, Part Two

Non-Brain Death Organ Donation Part Two

By Nancy Valko, RN, ALNC

February 20, 2015

(This is an updated version of an article originally published in the February newsletter of the Pro-Life Healthcare Alliance .

Although non-brain death organ donation started over 20 years ago, it is mostly unknown to the  general public who sign organ donor cards assuming that they will be carefully diagnosed as  “brain dead” before their organs are harvested. (See “Non-Brain Death Organ Donation, Part  One,” )

Originally called non-heart beating organ donation (NHBD), and later DCD (donation after cardiac death), it is now called donation after circulatory death (also DCD) because donor hearts can sometimes be restarted for transplantation. I call it non-brain death organ donation because “brain death” criteria are not used.

In March, 2011, the Organ Procurement and Transplantation Network (OPTN) published proposed policy rules on non-brain death organ donation and opened its website for public comments. Despite many critical comments and an article in the Washington Post titled “Changes in controversial organ donation method stir fears” [1], the OPTN has now finalized some very dismaying standards.[2]

In one of the most disturbing sections, “Consent for DCD”, the OPTN states that “Conditions involving a potential DCD donor being medically treated/supported in a conscious mental state will require that the OPO (organ procurement organization) confirms that the healthcare team has assessed the patient’s competency and capacity to make withdrawal/support and other medical decisions.” [Emphasis added.] There is no mention of evaluation for depression or other difficulties that may influence the person’s decision, which omission obviously could lead to a new form of assisted suicide.

The OPTN policies also state that “Any planned withdrawal of life sustaining medical treatment/support will be carried out in accordance with hospital policy.” Even the guidelines suggested in the two Institutes of Medicine reports on non-brain death organ donation, like waiting a minimum 5 minutes (after cessation of the donor’s breathing and heartbeat) before harvesting, have been generally jettisoned in favor of locally decided rules. As the OPTN admits, its policies “…set the minimum requirements for DCD recovery but do not address local practices, cultural and resource issues…” Thus, like brain death criteria, the rules surrounding non-brain death donation can potentially vary even from hospital to hospital without the patient or family even being aware. And as one of the inventors of the NHBD protocol, Dr. Michael DeVita, has admitted, “the possibility of [brain function] recovery exists for at least 15 minutes.”[3]

Another major problem is that, even though doctors screen such patients for a rapid inability to continue breathing without a ventilator, at least an estimated 20 per cent of non-brain death donors do not stop breathing and heartbeat fast enough after withdrawal of a ventilator to have usable organs. These patients are then just returned to their rooms to die without further treatment.[4]

How can doctors be so wrong in some cases? Could such patients potentially improve? A 2003 article in the New England Journal of Medicine illustrated a disturbing lack of objective medical standards for withdrawal of ventilators even outside an organ donation decision. This article admitted that no study was done to “validate physician predictions of patients’ future functional status and cognitive function” and the researchers did not ask doctors to ”justify their predictions of the likelihood of death or future function.”[5]

These are just a few of the criticisms of non-brain death organ donation that have been raised by ethicists, doctors and other concerned people.

Informed Consent

 How many people know the Uniform Anatomical Gift Act was revised in 2006 to include “first person” authorization when a person signs an organ donor card or other legal donation document that “not only continues the policy of making lifetime donations irrevocable but also is restated to take away from families the power, right, or authority to consent to, amend, or revoke donations made by donors during their lifetimes.”[6]?

With the discussion about problems with non-brain death organ donation absent in mainstream media, what can you do to protect yourself from a potentially unwanted organ donation?

First of all, know the facts. It is necessary to do your own research since fact sheets often provide only minimal information when you sign an organ donor card while you are renewing your driver’s license or checking off a box in your advance directive. Therefore, you may not be giving the truly informed consent such a momentous decision requires.

Keep informed about new strategies being proposed such as “presumed consent” which is the assumption that everyone is willing to donate his/her organs unless there is evidence that they would not want to donate. Illinois narrowly avoided a “presumed consent” statute a few years ago.

However, there are alternative ways to donate that people who are uncomfortable with brain death and/or non-brain death donation might consider. For example, people can become a living organ donor for a kidney. Such kidneys also have many advantages over both brain dead and non-brain dead kidneys such as usually lasting twice as long. (See: “The Benefits of Living Donation”) While there are risks to such a surgery for the donor, living organ donation avoids the ethical concerns about determining death.

Other alternatives are the donation of blood or bone marrow donor while living or, after death, the donation of tissues like bone or corneas that can be taken even hours after death is certain.

In addition, there is hopeful medical research involving adult stem cells to repair organs and building artificial organs that may someday replace the organ donation we have now.

Having a daughter-in-law who currently needs a living donor kidney transplant, I am aware of how much such a “gift of life” can mean, but I believe it should not be at the expense of ethics or informed consent.

About the author: Nancy Valko, RN, ALNC, has been a registered nurse for 45 years and is a spokesperson for the National Association of Prolife Nurses . A long-time speaker and writer on medical ethics and other health issues, she has a blog “A Nurse’s Perspective on Life, Healthcare and Ethics” and an archive of her articles from 1988-2014 titled “Nancy Valko, RN ALNC”.  She is also now a legal nurse consultant.

FOOTNOTES

[1] “Changes in controversial organ donation method stir fears” by Rob Stein. Washington Post, September 19, 2011. Online at:  http://www.washingtonpost.com/national/health-science/changes-in-controversial-organ-donation-methodstir-fears/2011/09/15/gIQAlY9agK_story.html

[2] Organ Procurement and Transplantation Network Policies. U.S. Department of Health & Human Services. Current as of 2/1/2015. Online at http://optn.transplant.hrsa.gov/ContentDocuments/OPTN_Policies.pdf

[3]”The Death Watch: Certifying Death Using Cardiac Criteria,” Michael A. DeVita, MD, University of Pittsburgh Medical Center, Pittsburgh, Pa., Prog. Transplant 2001; 11(1):58-66, © 2001 North American Transplant Coordinators Organization

[4] “Organ Procurement after Cardiocirculatory Death: A Critical Analysis”, Mohamed Y. Rady, MD, PhD, Joseph L. Verheijde, PhD, MBA, and Joan McGregor, PhD. Journal of Intensive Care Medicine. September/October 2008, available online at http://jic.sagepub.com/cgi/reprint/23/5/303.pdf

[5] Withdrawal of Mechanical Ventilation in Anticipation of Death in the Intensive Care Unit” by Deborah Cook, M.D., et al. New England Journal of Medicine, Volume 349:1123-1132, September 18, 2003, Number 12. Abstract available online at: http://content.nejm.org/cgi/content/short/349/12/1123

[6] REVISED UNIFORM ANATOMICAL GIFT ACT (2006), page 30. Online at: http://www.uniformlaws.org/shared/docs/anatomical_gift/uaga_final_aug09.pdf

Non-Brain Death Organ Donation, Part One

January 12, 2015

Non-Brain Death Organ Donation

 

By Nancy Valko, RN ALNC

Would you sign an organ donor card if you knew that you didn’t necessarily have to be diagnosed as “brain dead” before your organs were removed? Would you sign an organ donor card if you knew that the card would override your family if they objected?

These scenarios might sound far-fetched but they are very real today even though unknown to most people. The understandable zeal to obtain organs and tissues for transplantation has gone much farther than most people realize when they agree to future organ donation.

The current non-brain death organ donation policy started with ethics journal articles in the mid-1990s when it was called “non-heart beating donation” and promoted as a way to increase the supply of organs to transplant beyond the “brain death” organ donations. This was accomplished by linking organ donation with withdrawal of treatment decisions from people considered hopelessly ill or dying but who did with not meet the criteria for “brain death”. This change in policy came in the wake of court decisions upholding the right to refuse treatment for incapacitated patients like Nancy Cruzan, a brain-injured woman said to be in a so-called “vegetative state.”

Since Dr. Isajiw and I presented the following paper in 2004, the term “non-heart beating organ donation” has been changed to “donation after cardiac death” and around 5% of organs donated in the US now come from such donors. (Source: The Challenge of Organ Donation after Cardiac Death” by Matt Wood. February 20, 2014. Science Life. Online at: http://sciencelife.uchospitals.edu/2014/02/20/the-challenge-of-organ-donation-after-cardiac-death )

Moreover, there is now “first person consent” law that considers a signed organ donor card the legal and ethical equivalent of signing an advance directive. This means that no one (not even family) can then override the decision to donate organs. (Source: “If I sign an organ donor card, will my wishes be carried out?” by Katrina Bramstedt, PhD. Online at: http://www.sharecare.com/health/organ-transplants-and-health-care/sign-organ-donor-card)

 

Other new developments include efforts to pass “presumed consent” laws that change the organ donation system from one that requires a person to “opt-in” for organ donation to an “opt-out” system that presumes everyone is automatically an organ donor unless they have specifically refused. Recently, Illinois was set to be the first state to approve a “presumed consent” bill before it was narrowly defeated with the help of disability organizations.

People sign organ donor cards because they sincerely want to help save or improve the lives of others after they themselves die but without adequate information, is this truly informed consent?

2.http://www.wf-f.org/NHBD-VatMar2004.html

“Non-heart beating Organ Donation and the ‘Vegetative State’” (2004)

Editor’s Note: The following was presented by Dr. George Isajiw to the participants in the International Congress on “Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas”, held in Rome March 17-20, 2004.

On May 23, 2003, the newspaper of the Archdiocese of St. Louis, the St. Louis Review, published an editorial stating that “the NHBD (non-heart beating organ donation) protocol is cruel and dangerous and does not meet standards of respect for human life” and called for an immediate moratorium on NHBD at all St. Louis hospitals.

Reaction was swift and critical. The St. Louis Post-Dispatch cited transplant surgeons and others who defended NHBD as a way to increase organ donations by taking organs from patients who “have little brain activity and are in a vegetative state with no hope of recovery and whose families decide to discontinue life support.1 Michael Panicola, vice president of ethics for the Catholic SSM Healthcare System, defended NHBD as “an opportunity for people to give the gift of life when they don’t meet brain death criteria.”

FACTS ABOUT NON-HEART BEATING ORGAN DONATION

For the past several years, a little-known but disturbing revolution has been occurring in organ donation. In the understandable but sometimes alarming zeal to obtain more organs, a new procedure called “non-heart-beating organ donation” has been quietly added to brain death organ donation in more and more hospitals in the United States and in other countries.2

Here, we are referring only to so-called “controlled NHBD protocols, although the “uncontrolled NHBD protocols, which are used for patients who have failed resuscitation efforts, have their own set of ethical problems which overlap with “controlled” NHBD, such as cannulation for preservation of organs before consent can be obtained.

While brain death organ donation means that the person is legally dead but still has a heartbeat when organs are harvested, the potential NHBD patient does not meet the brain death criteria but is termed “hopeless” or “vegetative” soon after suffering a devastating condition such as a severe stroke or trauma, and while still needing a ventilator to breathe. Because of the legal acceptance of the so-called “right to die”, families or other surrogates then agree to have the ventilator turned off, a “do not resuscitate” order is written, and when the patient’s breathing and heartbeat stops, the organs are removed.

In NHBD, the ventilator is usually stopped in an operating room while a doctor watches for up to one hour until the heartbeat and breathing stops. After an interval of usually just 2 to 5 minutes, the patient is declared dead and the transplant team takes over to remove the organs. A determination of brain death is considered unnecessary even though one of the inventors of the NHBD protocol, Dr. Michael DeVita has admitted, “the possibility of [brain function] recovery exists for at least 15 minutes”. Nonetheless, Dr. DeVita defends waiting only 2 minutes before harvesting the organs because he believes that the person is unconscious and, as he writes, “the 2-minute time span probably fits with the layperson’s conception of how death ought to be determined”.3

A recent article in the New England Journal of Medicine illustrates the disturbing lack of objective medical standards for withdrawal of ventilators.4 This article, published in September of 2003, admits that no study was done to “validate physicians’ predictions of patients, future functional status and cognitive function”, and the researchers did not ask doctors to ”justify their predictions of the likelihood of death or future function”.

With such subjective standards being used for withdrawal of ventilators, it should not be surprising that the potential NHBD patient will unexpectedly continue to breathe for longer than the usual one hour time limit required for the organ transplant to be successful. In these cases of failed NHBD, the transplant is then cancelled but, rather than resuming care, the patient is just returned to his or her room to eventually die without any treatment or further life support.

The recent case of Jason Childress illustrates the lethal problems with this non-treatment plan and the lack of objective medical or ethical standards for withdrawing ventilators.5

Jason is a young man who was severely brain-injured in a car accident and became the subject of a “right to die” case in which the judge ordered the removal of his ventilator 2 months after his accident. Against all predictions and because his tube feedings were not also stopped, Jason continued to breathe on his own and is now showing signs of improvement and receiving treatment. Ominously, the doctors, initial recommendation to withdraw the ventilator 2 days after his accident could have made him a prime candidate for NHBD since he would have possibly been too injured to breathe on his own that soon after his accident. The rush to declare patients “hopeless or “vegetative soon after illness or injury can thus deprive at least some patients of the chance of survival or even recovery.6

Some NHBD protocols do not even require that the donor be mentally impaired at all. For example, one ethicist wrote about the case of a fully conscious man with ALS who decided to check himself into a hospital, have his ventilator removed and donated his organs under NHBD criteria. The ethicist wrote, “An operating room nurse reported feeling that the procedure was ‘Kevorkian-like'”.7

CONCLUSION Even more pressure to increase the use of NHBD is apparently coming in the US, even though the public has been kept largely uninformed about this new method of obtaining organs. For example, last November, an advisory committee to the US Health and Human Services department recommended that, in the future, all hospitals should establish policies and procedures to “manage and maximize” NHBD and also be required to “notify organ procurement organizations prior to the withdrawal of life support to a patient, so as to determine that patient’s potential for organ donation”. Unknown to most of the public, hospitals are now already required to report every death to the local transplant organization even when tissue or organ donation is refused and, if enacted, this new proposal will put further pressure on medical personnel and distraught families.

Ironically, at the same time, new information is coming forward about these so-called “hopeless” patients who are considered potential NHBD candidates. A September 2003 article in the New York Times featured the work of Dr. Joseph T. Giacino and others with people who have had severe brain damage but who are now showing signs of “complex mental activity even after months or years with little sign of consciousness”.9 And, of course, there are many reported cases even in the media of brain-injured people who improve or even recover long after the doctors declared them hopeless.

Yet, even this may not be enough for some ethicists like Dr. Robert Truog, who recently proposed that “individuals who desire to donate their organs and who are either neurologically devastated or imminently dying should be allowed to donate their organs, without first being declared dead.”10 In other words, Dr. Truog wants to eliminate even the controversial NHBD protocol in favor of just taking organs from incapacitated or dying patients while they are obviously still alive.

Linking the so-called “right to die” with organ donation, as NHBD does, has truly opened a terrible Pandora’s box. While organ donation can be a gift of life and a worthy goal, we must not allow the deaths of some people to be manipulated to obtain organs for others. The position of Cardinal Justin Rigali, now Archbishop of Philadelphia, who was at that time the Archbishop of St. Louis and who asked for an immediate moratorium and re-evaluation of NHBD, is eminently sensible and should be replicated worldwide.

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NOTES

[1] “Archdiocese criticizes some organ retrievals by Deborah L. Shelton, St. Louis Post-Dispatch, 6/10/03.

[2] “It is difficult to determine whether other countries such as Holland and Japan adopt a uniform defensible template in their practice of controlled NHBOD and information from the UK is also extremely limited as to the extent and nature of practice”. From “Non-heart beating organ donation: old procurement strategy” new ethical problems by M. D. Bell, Journal of Medical Ethics 2003; 29:176-181. Online at: http://jme.bmjjournals.com/cgi/content/full/29/3/176

[3] “The Death Watch: Certifying Death Using Cardiac Criteria” by Michael A. DeVita, MD, University of Pittsburgh Medical Center, Pittsburgh, Pa. Prog. Transplant 11(1):58-66, 2001. © 2001 North American Transplant Coordinators Organization

[4] “Withdrawal of Mechanical Ventilation in Anticipation of Death in the Intensive Care Unit” by Deborah Cook, M.D., et al. New Englnad Journal of Medicine, Volume 349:1123-1132, September 18, 2003, Number 12. Abstract available online at: http://content.nejm.org/cgi/content/short/349/12/1123

[5] “Jason Childress Still Breathing, Receives Proper Medical Care” by Steven Ertelt, LifeNews.com Editor, September 25, 2003. Available online at: http://www.lifenews.com/bio58.html

[6] “Ethical Implication of Non-Heart Beating Organ Donation” by Nancy Valko, RN. Voices magazine, Michaelmas 2002 Volume XVII, No. 3. Online at: http://www.wf-f.org/02-3-OrganDonation.html

[7] A Primer for Health Care Ethics by Kevin O’Rourke, O.P., Georgetown University Press, 2000, p. 182

[8] US Department of Health and Human Services Advisory Committee on Organ Transplantation, Recommendations to the Secretary. November 2002. Available online at: http://www.organdonor.gov/acotrecsbrief.html

[9] “What if There Is Something Going On in There?” by Carl Zimmer. New York Times, 9/28/03

[10] “Role of brain death and the dead-donor rule in the ethics of organ transplantation” by Robert D. Truog, MD, FCCM; Walter M. Robinson, MD, MPH. Critical Care Medicine Journal, September 2003; 31(9):2391-2396

George Isajiw, M.D., is based in Washington, DC, and is Internal Medicine Consultant to the Linacre Institute of the Catholic Medical Association. He is also past president of the Catholic Medical Association, USA. His 2002 paper “Advance ‘Mis-Directives’: Euthanasia in Catholic Hospitals in the United States” appears here.

Nancy Valko, a registered nurse, is president of Missouri Nurses for Life, a spokesperson for the National Association of Pro-life Nurses and a Voices contributing editor. She is based in St. Louis, MO.