LIFE, DEATH, AND HEART

TRANSPLANTATIONS Dorothy Peters, R.N.

In Ecclesiastes it is written, “To everything there is a season, and a time to every pur- pose under heaven: A time to be born and a time to die . . .” (Ecc. 3:l-2). Yet the ques- tion now at hand is: Does man have the right to determine the time of death?

On an evening toward the end of April, 1969, a 36 year-old man was critically beat- en in a brawl. He was taken to a hospital and remained in critical condition for several weeks. Meanwhile, in another hospital near- by, a 62 year-old man, suffering with a severely diseased heart, was fighting to stay alive. In May, 1968, the first man was de- clared dead, a flat line on the electroenceph- alograph indicating that his brain had ceased to function. His heart, however, was still faintly beating because of mechanical de- vices used to continue his vital functions of blood circulation and respiration. Prepara- tions were made to transplant this man’s heart into the 62 year-old man. At 1:58 P.M., surgeons claim the donor’s heart ar- rested, and they therefore turned off the machine and began the heart transplantation.’

When did the donor die, at 10:30 A.M. or 1:58 P.M.? Is the person who beat this man in the brawl responsible for homicide or can the heart transplant team be charged with murder? What is life? Does man have the right to tamper with life’s natural pro- cesses or should we leave such “tampering”

Dorothy Ann Peters, R.N., received her training at Bethel Deaconess Hospital, Newton, Kansas, and is currently a candidate for a Bachelor of Science degree in Nursing at Goshen College, Goslim, Indi- ana. Miss Peters has also worked in the operating rnom of the St. Joseph Hospital and Rehabilitation Center, Wirhita, Kansas.

to Divine Providence? These are the issues which have been forced into the foreground since the recent advances made in the field of heart transplantation. The issues of life and death have confronted theology and medicine in what may prove to be a turning point in medical ethics.

Generally, theologians lean toward the conservative pole, holding views which seem rather idealistic for the present ethical cri- sis in medicine. For instance, theologians say that it is not our right to sacrifice one life for another, that any life can be useful to society, and that there is not a life that is not worth living.‘ Medicine, however, ap- proaches the problem from a more situa- tional angle. The doctor must apply his ethics in a practical manner and adapt them, within certain limitations, to meet the de- mands of the situation. There seems to be a continuous splitting of hairs between the two factions with no options offered toward resolving the conflict. I feel that certain op- tions exist, but a closer examination of both sides must first be made.

Life, in the theological sense, began as an act of God and continues as His act. God desires life and, therefore, He gives life. Dietrich Bonhoeffer has described life as “a plunge into a nothing or a void, movement to n ~ t h i n g . ” ~ Life is also a means to an end, as well as an end in itself. That is, in rela- tion to Christ, the status of life is creature- hood (the end in itself) and participation in the Kingdom of God (a means to an end) .4

Since life has the status of creaturehood, man is endowed with natural rights upon entering the world. It was God’s will that

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man be created, therefore man has the right to eternal life and God has guaranteed cer- tain individual rights. Bonhoeffer felt that each individual has the right to live as well as the right to die, but the individual must make the choice.

With the preceding discussion of natural life and individual rights, we advance to the next step of the right to bodily life. Theo- logians are split on this issue with Joseph Fletcher and situational ethics on one side, and Bonhoeffer and conservative ethics on the other. Fletcher, an advocate of euthana- sia, believes that the right to life does not commit you to live, especially if your exis- tence is hideous or demoralizing5 In a case where life is carried on in the state of a vegetable existence, termination of the per- son’s life would be warranted.

The conservative element, structured in the ethical roots of the Judeo-Christian tradi- tion, holds that life is the creative work of God. It is sacred and should not be tam- pored with by man.a Thus it becomes our responsibility to preserve life, to safeguard life from intentional injury and killing.

In the light of heart transplants does this ethic give us the right to sacrifice one life for the preservation of another? Fletcher would say it is permissible to take a life so long as the situation warrants it. But Bon- hoeffer would not agree. In the first place, any injury or destruction to the body of another constitutes the destruction of all the natural rights to life as God guaranteed them. Secondly, because of this claim to natural rights, all deliberate killing of inno- cent life is arbitrary.

One could imply, therefore, that considera- tion of the living, heart transplant recipient, would not warrant the taking of a life for the purpose of a heart transplant, even if the donor possessed a non-functioning brain. It seems that these conservative theolo,’ uians are afraid that death would become an imperson- al entity. One is reminded of the vulture on

the desert who circles around and finally attacks his victim, killing him. In somewhat the same manner, one could picture a heart transplant team hovering over an accident, waiting for the patient to die so that a trans- plant of his vital organs can be carried out. However, this situation seems very unreal- istic and most certainly does not follow the ethical guidelines of the present medical pro- fession.

The medical side of the problem confronts the critical decision of determining the exact moment of death. This decision has become more crucial now that heart transplant teams are waiting to begin surgery almost imme- diately. Greater success is obtained in the transplant if the organ is oxygenated for the longest possible period of time. Therefore, if the heart is still beating when it is lifted out of the corpse, a better measure of success will be obtained.

A traditional view of death maintains that when heart beat and breathing stop, all of life’s functions have ceased. In recent months, a second view has spread among the members of the medical profession, a view which states that death occurs when the brain permanently ceases to function. This has created many questions on both sides and as a result, many physicians are now utilizing these five criteria for death:

1) Complete dilatation of the pupils with no reflex response to light

2) Complete absence of spontaneous res- piration after mechanical respiration has been turned off for five minutes

3) Complete absence of muscle and ten- don reflexes to very painful stimuli

4) Constantly falling blood pressure af- ter large doses of hypotensive drugs have been administered

5) An electroencephalogram which is flat for several minutes.s Of these five criteria, not one mentions the cessation of the heart beat. In the case cited at the beginning of this paper, the donor’s

April 1969 39

heart had arrested at which time he was pronounced dead. There is no formal agree- ment as to when death occurs. This deci- sion becomes very critical and demands mor- al courage on the part of the physician who makes it. There are no rigid rules, only the conscience of the physician.

The ethical problems which follow the decision to perform a transplant are many, but two of them demand further exploration. First, the question is raised as to who gives consent for the procedure in the case of both the donor and the recipient. In both in- stances, permission may be given while the family is in a state of high emotional stress. If the immediate family of the donor is un- able to make the decision, who then gives consent? In the same way, the recipient is also caught in the clutches of emotional strain: If he does not go through with the transplant, he will soon die. Yet if he does have the transplantation, will he survive the massive change his body must undergo to accept a foreign substance?9

The second ethical question raised is: Who shall receive a new heart? A heart trans- plant is an expensive procedure and because of this fact will the rich be the ones to live and the poor the ones to die? What about crossing racial and cultural barriers? Pos- sible criteria include:

1 ) General health 2 1 Moral character 3) Family responsibility 4) Value to the community 5 ) Wealth'" A decision must be made by both the phy-

sician and the patient as to whether a heart transplant should be performed or per- mitted. This decision should be based on intelligently reasoned-out criteria and not on an emotional choice. Dr. Chrisitan Barnard has said, "The ethical imperative of the hour is that concern for an individual and concern for humanity enrich each other.""

The common core of these last two ethical

questions seems to suggest that humanity is worried about what the eventual outcome of medical progress might be. Some theolo- gians seem to think that medicine is stepping outside its boundaries to play God through some of its recent advances. No one can determine the full impact of deciding who shall live or who shall die. Perhaps if these theologians were faced with making a deci- sion of this type, more consideration to the situation of the individual would be given, for it is the individual that most physicians consider. All of us are human beings and we will never be able to set up a standard of ethics which explicitly states what should or should not be allowed to happen in medicine. Medical science has to fuse common sense and integrity into human matters in order to control medical experiments. It must always place high value on human life before ex- perimenting with a new machine or discov- ery which could improve the health of man.

Resolving these ethical problems becomes the major concern of both religion and med- ical science. Can the conflict between reli- gion and medicine be resolved? I feel Lhat three options exist and that they can be possible solutions to the questions raised. These options are as follows:

1) Making use of borderline ethics 2) Discovering a different attitude toward

death 3) The way of Brotherly Love

First of all, one could make use of what Helmut Thielicke calls borderline ethics. The higher goal is the end, but the means to the end may demand setting aside the interven- ing command about the sanctity of life anti property.'? Medical science could resolve the problem posed by its advances by saying that the goal of a healthier and happier life for man justifies a means which might not be ethically up to par. Theologians would most certainly voice their disapproval be- cause such a resolution would allow man the right to Divine Authority, a right that man

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is incapable of handling. Most doctors would shun this approach too, since it con- flicts with the Hippocratic Oath.

In the second approach, the need arises to discover a new attitude toward death. Death has always been pictured as the enemy. Sel- dom after a death has occurred do we feel that victory and a new life have been ob- tained for the person. When a patient dies, the medical and nursing personnel take on an air of defeat. If death were accepted in some other attitude rather than defeat, would we have the problem of deciding when death occurs? Would we be involved in all of these moral, legal, and ethical problems which face our heart transplant teams and society in general? Until all men cease to fear death and until death becomes the be- ginning of a new life for all men, society will continue to be plagued with these prob- lems in medical ethics.

This approach is very idealistic and one would have to be absurd to think that such a resolution could be reached. This resolu- tion does not exist as a possibility and, per- haps, could be useful to a slight degree only if one faction would change its attitude re- garding death. The changes one segment of the medical profession, perhaps the nursing

profession, could bring about would be as- tounding, especially if a chain reaction were to be produced in other areas of medicine.

The final approach is the way of Brotherly Love: “Love your neighbor as yourself” (Matt. 22:37-39). Our priority will be, then, to love our brother at all times, thereby exhih- iting concern for him no matter what the situation is. Paul Rhoads believes the ethical approach will come to this: “If the doctor is sincerely and selflessly trying to do the best for his patient, he is more likely to take the right course than if we try to draw up hard and fast rules to guide him in all cases.”13

I feel that the basic issue raised in the ethics of life and death comes from the broader issue of how religion and science can be relative to life, To a physician, his religion may be threatened by the scientific method of seeking solutions. In medicine, everything is factual and can be reasoned out; but religion does not claim to have a reason for everything.

Decisions of life and death are not easily made. The establishment of an inter-personal system of values is essential in coping with these decisions and is the primary structure on which science and religion can exist in harmony.

REFERENCES

1 . “Redefining Death,” Newsweek, May 20, 1968, 11. 68. 2. Bonhoeffer, Dietrich, Ethics, The hlacmillan Com- pany, New York, 1962, p. 119. 3. Ibid., 1’. 106. 4. Ibitl., p. 107. 5. Flrtchrr, Joseph, Morals and Medicine, Beactrn Press, Boston, 1960, p. 188. 6. Baker, Charles W., “Thanatopsis,” The Christian Century, Drrrmlier 7, 1966, p. 1504. 7. Bonhoeffer, Op. c k , p. 112. 8. Rhoads, Paul S., M.D., “Moral Considerations in Prolongation of Life,” Chapel-Convocation Lecture, Goslim Cnllrg~, Goshrn, Indiana, May 10, 1968.

9. Vaux, Kenneth, “The Heart Transplant: Ethical Dimensions,” The Christian Century, March 20, 1968, p. 355. 10. Appel, James, “Ethical and Legal Questions Posed by Recent Advances in Medicine,” Journal of the Anierican Medical Association, August 12, 1968, p. 515. 11. Vaux, Op. cit., p. 354. 12. Thielicke, Helmut, Theological Ethics, Vol. 1 Foundations, ed. William Lazareth, Fortress Press, Phi!adelphia, 1966, p. 632. 13. Rhoads, Paul S., M.D., “Medical Ethics and Morals in a New Age,” Journal of the American Mediral Association, August 12, 1968, p. 520.

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