Organ Transplantation, Organ Transplantation, (Brain) Death, and(Brain) Death, andAdvance DirectivesAdvance Directives

Saint Cecilia MotherhouseBioethics Workshop

July 10, 2010Sister Mary Diana Dreger, O.P., M.D.

The risk of dying is The risk of dying is decreased in those who decreased in those who

exercise regularly. exercise regularly.

Because of the lack of Because of the lack of available donorsavailable donors in this in this country, 4,573 kidney country, 4,573 kidney patients, 1,506 liver patients, 1,506 liver patients, 371 heart patients, 371 heart

patients and 234 lung patients and 234 lung patients diedpatients died in 2008 while in 2008 while

waiting for life-saving waiting for life-saving organ transplants. organ transplants.

It is surely a reason for satisfaction It is surely a reason for satisfaction that many sick people, who until that many sick people, who until recently could only expect death or at recently could only expect death or at best a painful and restricted existence, best a painful and restricted existence, can now recover more or less fully can now recover more or less fully through the replacement of a diseased through the replacement of a diseased organ with a healthy donated one. organ with a healthy donated one. We We should rejoice that should rejoice that medicine, in its medicine, in its service to life, has found in organ service to life, has found in organ transplantation a new way of serving transplantation a new way of serving the human familythe human family, precisely by , precisely by safeguarding that fundamental good of safeguarding that fundamental good of the person. the person.

Pope John Paul II, Pope John Paul II, 19911991

Address to First International Address to First International Congress Congress

of the Society for Organ of the Society for Organ SharingSharing

……there is an everyday heroism, there is an everyday heroism, made up of gestures of sharing, made up of gestures of sharing, big or small, which build up an big or small, which build up an authentic culture of life. A authentic culture of life. A particularly praiseworthy example particularly praiseworthy example of such gestures is the donation of of such gestures is the donation of organs, performed in an organs, performed in an ethically ethically acceptable manneracceptable manner, with a view to , with a view to offering a chance of health and offering a chance of health and even of life itself to the sick who even of life itself to the sick who sometimes have no other hope. sometimes have no other hope.

Pope John Paul IIPope John Paul IIEvangelium VitaeEvangelium Vitae

In this area of medical science too In this area of medical science too the the fundamental criterion must be fundamental criterion must be the the defence and promotion of the integral defence and promotion of the integral good of the human persongood of the human person, in keeping , in keeping with that unique dignity which is ours with that unique dignity which is ours by virtue of our humanity. by virtue of our humanity. Consequently, it is evident that every Consequently, it is evident that every medical procedure performed on the medical procedure performed on the human person is subject to limits: not human person is subject to limits: not just the limits of what it is technically just the limits of what it is technically possible, but also limits determined by possible, but also limits determined by respect for human nature itself, respect for human nature itself, understood in its fullness…. understood in its fullness….

Pope John Paul II, Pope John Paul II, 20002000Address to International Congress on Address to International Congress on TransplantsTransplants

Good of the human Good of the human personperson

• Organ donor– Informed consent– First do no harm– Not an object of exchange

• Organ recipient– Informed consent– Contextual understanding– Not an object of medical science

Tissues/organs for Tissues/organs for transplanttransplant

• Tissues:– Blood (living donor)– Bone, cartilage, cornea, heart

valves (from cadaver/corpse)

• Organs:– Kidney, lobe of a liver (living donor)– Heart, lungs, liver

Donor cannot live

without these

Dead Donor Rule (DDR)Dead Donor Rule (DDR)

• The donor must be dead before a vital, unpaired organ may be removed for transplant

• Criteria for death can vary

DeathDeath

• Separation of body and soul (philosophical)

• How do we measure this? (scientifically)

Measures of DeathMeasures of Death

• Cardiopulmonary criteria• Artificial ventilation steps in• Neurological criterion

CONCEPT: brain as the “unifying principle” which “integrates” the human person – without the brain, the human life “disintegrates”

Brain DeathBrain Death

• That is, death of the body by neurologic criteria

• 1968 – Harvard paper• “Total brain failure”• Brain dead means dead

It is a well-known fact that for some It is a well-known fact that for some time certain scientific approaches to time certain scientific approaches to ascertaining death have shifted the ascertaining death have shifted the emphasis from the traditional cardio-emphasis from the traditional cardio-respiratory signs to the so-called respiratory signs to the so-called "neurological" criterion"neurological" criterion. . Specifically, Specifically, this consists in establishing, according this consists in establishing, according to clearly determined parameters to clearly determined parameters commonly held by the international commonly held by the international scientific community, the scientific community, the complete and complete and irreversible cessation of all brain irreversible cessation of all brain activity (in the cerebrum, cerebellum activity (in the cerebrum, cerebellum and brain stem)and brain stem). This is then considered . This is then considered the sign that the individual organism the sign that the individual organism has lost its integrative capacity. has lost its integrative capacity. Pope John Paul II, Pope John Paul II, 20002000Address to International Congress on Address to International Congress on TransplantsTransplants

With regard to the parameters used With regard to the parameters used today for ascertaining death -  whether today for ascertaining death -  whether the "encephalic" signs or the more the "encephalic" signs or the more traditional cardio-respiratory signs - traditional cardio-respiratory signs - the the Church does not make technical Church does not make technical decisionsdecisions. She limits herself to the . She limits herself to the Gospel duty of comparing the data Gospel duty of comparing the data offered by medical science with the offered by medical science with the Christian understanding of the unity of Christian understanding of the unity of the person….the person….

Pope John Paul II, Pope John Paul II, 20002000 Address to International Congress on Address to International Congress on TransplantsTransplants

Here it can be said that the criterion Here it can be said that the criterion adopted in more recent times for adopted in more recent times for ascertaining the fact of death, namely ascertaining the fact of death, namely the the completecomplete and and irreversibleirreversible cessation cessation of all brain activityof all brain activity, if rigorously applied, , if rigorously applied, does not seem to conflict with the does not seem to conflict with the essential elements of a sound essential elements of a sound anthropology.anthropology.

Pope John Paul II, Pope John Paul II, 20002000 Address to International Congress on Address to International Congress on TransplantsTransplants

Current ControversiesCurrent Controversies• 1998: Alan Shewmon (UCLA

neurologist) – case series of patients (cadavers?) – integrative functions appear to still be present

• Confusion with PVS (persistent vegetative state)

• Controlled donation after cardiac death (controlled DCD)

• Abandoning the dead donor rule

The President’s Council The President’s Council on Bioethicson Bioethics

• December 2008• Chairman: Edmund Pellegrino,

M.D.• “Controversies in the

Determination of Death”• Presented two positions (against

and for…. but a qualified for)

With regard to the parameters used With regard to the parameters used today for ascertaining death -  whether today for ascertaining death -  whether the "encephalic" signs or the more the "encephalic" signs or the more traditional cardio-respiratory signs - traditional cardio-respiratory signs - the the Church does not make technical Church does not make technical decisionsdecisions. She limits herself to the . She limits herself to the Gospel duty of comparing the data Gospel duty of comparing the data offered by medical science with the offered by medical science with the Christian understanding of the unity of Christian understanding of the unity of the person….the person….

Pope John Paul II, Pope John Paul II, 20002000 Address to International Congress on Address to International Congress on TransplantsTransplants

The Catholic ChurchThe Catholic Church

Central issuesCentral issues

• The good of one person cannot be placed over the good of another

• Definition of death (and believing this is important) leads to ways to make moral choices

• Moving toward a society that is unsure of how to define death, and not sure that this is important

Advance DirectivesAdvance Directives

• Durable Power of Attorney for Health Care

• Living Will• The Five Wishes• POST or POLST forms

New directionsNew directions

• From New York….• Specially equipped ambulances• A proposed bill to presume donor

status

Do not fear the one who Do not fear the one who can kill the body, but the can kill the body, but the

one who can kill both one who can kill both body and soul.body and soul.