Skip to comments.Role of brain death and the dead-donor rule in the ethics of organ transplantation.
Posted on 10/14/2003 7:09:32 PM PDT by MarMema
Department of Anesthesiology, Harvard Medical School,
Cambridge, MA, USA.
The "dead-donor rule" requires patients to be declared dead before the removal of life-sustaining organs for transplantation.
The concept of brain death was developed, in part, to allow patients with devastating neurologic injury to be declared dead before the occurrence of cardiopulmonary arrest. Brain death is essential to current practices of organ retrieval because it legitimates organ removal from bodies that continue to have circulation and respiration, thereby avoiding ischemic injury to the organs.
The concept of brain death has long been recognized, however, to be plagued with serious inconsistencies and contradictions. Indeed, the concept fails to correspond to any coherent biological or philosophical understanding of death.
We review the evidence and arguments that expose these problems and present an alternative ethical framework to guide the procurement of transplantable organs. This alternative is based not on brain death and the dead-donor rule, but on the ethical principles of nonmaleficence (the duty not to harm, or primum non nocere) and respect for persons.
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.
Advantages of this approach are that (unlike the dead-donor rule) it focuses on the most salient ethical issues at stake, and (unlike the concept of brain death) it avoids conceptual confusion and inconsistencies.
Finally, we point out parallel developments, both domestically and abroad, that reflect both implicit and explicit support for our proposal.
Dr. Robinson is a pediatric pulmonologist at Boston Children's Hospital. And the Associate Director of the Division of Medical Ethics at Harvard Medical School, where he runs the Medical Ethics Fellowship and the Program in the Practice of Scientific Investigation.
He received his BA in Philosophy at Princeton University, his MD from Emory University, and his MPH at the Harvard School of Public Health. He was a Fellow in the Program in Ethics and the Professions at the Kennedy School of Government in 1994-95 and 1998-99.
He is actively involved in the CF clinic at Children's Hospital, where he also serves as associate ethicist in the Office of Ethics. Dr. Robinson's academic interests focus on the ethical issues that arise in chronic illness, organ transplantation, and clinical research.
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"Imminently dying" or "neurologically devastated" are so hard to prove, not bright-line designations. Who has not known stories of people who were thought to be virtually dead, who rallied, sometimes for years more of life? How "devastated" is enough?
Granted, we have mechanisms for deciding when to "pull the plug" now. But it is hard enough to determine when someone is "dead," let alone trying to decide if that person is sufficiently nearly dead.
Close counts in horseshoes, but not in dying.
"In Singers philosophy, there is a crucial distinction between persons and nonpersons. Only persons have the right to live. Nonpersons can be killed without significant moral concern on the basis that their lives are "interchangeable" and "replaceable."
As one of his chief arguing points, Singer has rationalized the killing of human babies. In Practical Ethics, he supports the killing of newborns with hemophilia. As he writes: "When the death of a disabled infant will lead to the birth of another infant with better prospects of a happy life, the total amount of happiness will be greater if the disabled infant is killed. The loss of the happy life for the first infant is outweighed by the gain of a happier life for the second. Therefore, if the killing of the hemophiliac infant has no adverse effect on others it would . . . be right to kill him."
Singer reiterated the point, using a different example, in Rethinking Life and Death: The Collapse of Our Traditional Ethics: "To have a child with Downs syndrome is to have a very different experience from having a normal child. . . . We may not want a child to start on lifes uncertain voyage if the prospects are clouded. When this can be known at a very early stage of the voyage we may be able to make a fresh start. . . . Instead of going forward and putting all our efforts into making the best of the situation, we can still say no, and start again from the beginning."
His use of passive language does not blunt his meaning: Singer is advocating infanticide as a parental prerogative. In the most extreme form of his argument, he has even suggested that parents have 28 days in which to decide whether to keep or kill their infants.
When Singer gives examples of babies who are appropriate to kill, he usually writes or speaks, as above, of children born with disabilities. But it is important to note that under his thesis, disability has little actual relevance. Utilitarian considerations of maximizing happiness and reducing suffering are what count to Singer. Thus, if a parent is unhappy with the birth of a child, if that childs death will cause them more happiness than keeping it, or if keeping the child will make life less happy for potential future children, then infanticide is an acceptable alternative. (Perhaps Brian Peterson and Amy Grossberg, who recently pled guilty to manslaughter after they wrapped their newborn baby in plastic and then tossed him into a waste receptacle, should have called Singer as a defense witness instead of copping a plea. After all, they were simply maximizing their happiness and ending the life of a replaceable being.)
Singers attitudes about cognitively disabled people are equally abhorrent. He argues that cognitively disabled people who are incapable of "choosing" to live or die can be killed. This applies to people diagnosed as permanently unconscious (a notoriously misdiagnosed condition) and those who are conscious but not "rational or autonomous." In other words, brain-damaged people, those with significant mental retardation, and/or some forms of psychosis, are not persons and do not have a right to life. Singer writes in Practical Ethics that, "it is difficult to see the point of keeping such human beings alive, if their life, on the whole, is miserable."
".......Singer is invited to speak at seminars, symposia, and philosophy association conventions, throughout the world. His 1979 book, Practical Ethics, which unabashedly advocates infanticide, euthanasia, and decries "discrimination" based on species (a bizarre notion Singer labels "speciesism"), has become a standard text in many college philosophy departments. Singer is now so mainstream that he even wrote the essay on ethics for the Encyclopedia Britannica."
".....Those who are fighting a rear-guard action to protect the human rights of weak and medically vulnerable people in universities and in debates over public policy in the United States have benefited from the fact that Singer has spoken from the hinterlands-Monash University in Australia. But now, even that cold comfort is gone. Next year, Singer will become a permanent member of the Princeton University faculty, where he will be the Ira W. DeCamp Professor of Bioethics, a prestigious, tenured academic chair, at the universitys Center for Human Values."
I'm getting the feeling that the main reason that ivory-tower ethics programs exist, is to convince ordinary people, like me, that immoral actions are really ethical actions.
I remember when ethics programs began to sprout up. They were supposed to be the new way to promote morality, without promoting particular religions. We were told that things were much too complex in this modern world and we needed to have experts tell us right from wrong. The simple old idea of decent behavior toward each individual would no longer do.
The ethics-hucksters have thrown out the baby with the bathwater and have left us with a chipped and rusty basin.
It is amazing the Nazi-like mentality of some of our "compassionate" people who want everyone to be "happy" (everyone they don't kill, that is).
There is no foundation for ethics once a purely hedonistic standard ("happiness") is used. Any system based on hedonism is a reductio absurdium that will fail. Life is struggle. Life can still have meaning, whether circumstances are happy or not. These glib fools who talk about maximizing the happiness of the lucky few by killing many people judged to be "inferior" in some way (they are of the wrong class, or are physically unfit, or they think differently, or they don't belong to some "Master Race") -- these fools seem to think that they will live forever if only they can kill enough of the "inferior" people who are in their way.
It is instructive to see how many of the hedonistic philosophers immediately seek to maximize "happiness" by killing ever-increasing categories of "those people" (whoever "those people" happen to be at the moment). A system is truly bankrupt when its primary ethical question is not, "How must I live?" but is instead, "Who must I kill?"
I admit to being a "Double-Minded Man" on this subject -- as I, for one, have always offered myself as an "Organ Donor" since the first time I earned a Driver's License. While I am no Gnostic Heretic who denies the Resurrection of the Body, I am also convinced that, when I depart this mortal coil and my spirit rests (temporarily) in the Bosom of Abraham, I shall have no further need of my fleshly organs until the Day when the Final Resurrection is commenced; others, who have more need of them, may borrow them in the meanwhile.
I admit that there is a danger of "active euthanasia", which is a prospect to be abhorred; but as concerns myself, I have little worry. I try to be a good Calvinist of the "General Stonewall Jackson" school:
As dangerous as the State's attempts to seduce the Medical Establishment into the expedience of Active Euthanasia may be, I do not fear them over-much. Personally, I think that this whole "active euthanasia" issue is a trivial matter, a red herring, an also-ran of a Medical Ethics issue.
At the risk of beating a dead horse, I think that the entire foundation of Medical Ethics in America comes always and only down to ROE VS. WADE, and this is also the fulcrum on which the whole weight of Medical Ethics turns.
I am not a great fan of Doctors, Nurses, and Medicine in general; I have visited a Doctor only once in 15 years (when I was recently stricken with a case of Palsy), and I never visit the Dentist (I could chug sugary Colas all day long, every day, and my teeth are still perfect. Guess I chose my genetic parents wisely!!) For me, it always comes back to Roe Vs. Wade.
"Euthanasia" is a red herring. It all comes back to Roe Vs. Wade. It always comes back to Roe vs. Wade. IT'S ALL ABOUT ROE VS. WADE.
The Liberals understand this. This is why, though 25-35% of all Registered Democrats are at least nominally "Pro-Life", the Liberals will never permit a Pro-Lifer to speak at the Democrat National Convention. The EVIL Party (the Democrats) understand the Stakes better than the STUPID Party (the Republicans).
MAY GOD BE WITH HER TODAY.