Sunday, March 11, 2012

Brain Death Redux, or... So Rabbi Slifkin, what say thee now?...

Remember my contretemps (via R'Herschel Maryles) with Rabbi Slifkiny


A very relevant article appeared in yesterday's WSJ:




What You Lose When You Sign That Organ-Donor Card - WSJ.com


[ORGANS]Photo Illustration Joel Holland, Gallery Stock (photo)
Doctors don't have to tell you or your relatives what they will do to your body during an organ harvest operation because you'll be dead, with no legal rights.
The last time I renewed my driver's license, the clerk at the DMV asked if she should check me off as an organ donor. I said no. She looked at me and asked again. I said, "No. Just check the box that says, 'I am a heartless, selfish bastard.'"
Becoming an organ donor seems like a win-win situation. Some 3.3 people on the transplant waiting list will have their lives extended by your gift (3.3 is the average yield of solid organs per donor). You're a hero, and at no real cost, apparently.
But what are you giving up when you check the donor box on your license? Your organs, of course—but much more. You're also giving up your right to informed consent. Doctors don't have to tell you or your relatives what they will do to your body during an organ harvest operation because you'll be dead, with no legal rights.
The most likely donors are victims of head trauma (from, say, a car or motorcycle accident), spontaneous bleeding in the head, or an aneurysm—patients who can be ruled dead based on brain-death criteria. But brain deaths are estimated to be just around 1% of the total. Everyone else dies from failure of the heart, circulation and breathing, which leads the organs to deteriorate quickly.
The current criteria on brain death were set by a Harvard Medical School committee in 1968, at a time when organ transplantation was making great strides. In 1981, the Uniform Determination of Death Act made brain death a legal form of death in all 50 states.
The exam for brain death is simple. A doctor splashes ice water in your ears (to look for shivering in the eyes), pokes your eyes with a cotton swab and checks for any gag reflex, among other rudimentary tests. It takes less time than a standard eye exam. Finally, in what's called the apnea test, the ventilator is disconnected to see if you can breathe unassisted. If not, you are brain dead. (Some or all of the above tests are repeated hours later for confirmation.)
Here's the weird part. If you fail the apnea test, your respirator is reconnected. You will begin to breathe again, your heart pumping blood, keeping the organs fresh. Doctors like to say that, at this point, the "person" has departed the body. You will now be called a BHC, or beating-heart cadaver.
Still, you will have more in common biologically with a living person than with a person whose heart has stopped. Your vital organs will function, you'll maintain your body temperature, and your wounds will continue to heal. You can still get bedsores, have heart attacks and get fever from infections.
"I like my dead people cold, stiff, gray and not breathing," says Dr. Michael A. DeVita of the University of Pittsburgh Medical Center. "The brain dead are warm, pink and breathing."
You might also be emitting brainwaves. Most people are surprised to learn that many people who are declared brain dead are never actually tested for higher-brain activity. The 1968 Harvard committee recommended that doctors use electroencephalography (EEG) to make sure the patient has flat brain waves. Today's tests concentrate on the stalk-like brain stem, in charge of basics such as breathing, sleeping and waking. The EEG would alert doctors if the cortex, the thinking part of your brain, is still active.
But various researchers decided that this test was unnecessary, so it was eliminated from the mandatory criteria in 1971. They reasoned that, if the brain stem is dead, the higher centers of the brain are also probably dead.
But in at least two studies before the 1981 Uniform Determination of Death Act, some "brain-dead" patients were found to be emitting brain waves. One, from the National Institute of Neurological Disorders and Stroke in the 1970s, found that out of 503 patients who met the usual criteria of brain death, 17 showed activity in an EEG.
Even some of the sharpest critics of the brain-death criteria argue that there is no possibility that donors will be in pain during the harvesting of their organs. One, Robert Truog, professor of medical ethics, anesthesia and pediatrics at Harvard Medical School, compared the topic of pain in an organ donor to an argument over "whether it is OK to kick a rock."
But BHCs—who don't receive anesthetics during an organ harvest operation—react to the scalpel like inadequately anesthetized live patients, exhibiting high blood pressure and sometimes soaring heart rates. Doctors say these are simply reflexes.
What if there is sound evidence that you are alive after being declared brain dead? In a 1999 article in the peer-reviewed journal Anesthesiology, Gail A. Van Norman, a professor of anesthesiology at the University of Washington, reported a case in which a 30-year-old patient with severe head trauma began breathing spontaneously after being declared brain dead. The physicians said that, because there was no chance of recovery, he could still be considered dead. The harvest proceeded over the objections of the anesthesiologist, who saw the donor move, and then react to the scalpel with hypertension.
Organ transplantation—from procurement of organs to transplant to the first year of postoperative care—is a $20 billion per year business. Average recipients are charged $750,000 for a transplant, and at an average 3.3 organs, that is more than $2 million per body. Neither donors nor their families can be paid for organs.
It is possible that not being a donor on your license can give you more bargaining power. If you leave instructions with your next of kin, they can perhaps negotiate a better deal. Instead of just the usual icewater-in-the-ears, why not ask for a blood-flow study to make sure your cortex is truly out of commission?
And how about some anesthetic? Although he doesn't believe the brain dead feel pain, Dr. Truog has used two light anesthetics, high-dose fentanyl and sufentanil, which won't harm organs, to quell high blood pressure or heart rate during harvesting operations. "If it were my family," he said, "I'd request them."
—Mr. Teresi is the author of "The Undead: Organ Harvesting, the Ice-Water Test, Beating-Heart Cadavers—How Medicine Is Blurring the Line Between Life and Death."

18 comments:

Charlie Hall said...

" In 1981, the Uniform Determination of Death Act made brain death a legal form of death in all 50 states."

This is a false statement; each state has to act independently. And not all states have done so:

http://www.nccusl.org/Act.aspx?title=Determination%20of%20Death%20Act

Charlie Hall said...

It should be pointed out that without the brain death criteria, there would be no heart transplants -- none, zero, nada. A donor heart has to come from a living breathing body, and by the death standard of anything other than brain death, the donor is murdered by the transplant doctors for the direct benefit of the recipient.

Charlie Hall said...

New York requires two independent neurological examinations before someone can be confirmed to be brain dead. A year ago an article examined over 1300 cases of brain death. The number of individuals who were found to have regained brainstem function by the time of the second exam was zero.

http://www.neurology.org/content/76/2/119.abstract

Anonymous said...

intuitively, what charlie hall says makes sense.
the author of the article clearly has an ax to grind.

Anonymous said...

This is what R. Slifkin says:

http://www.rationalistjudaism.com/2012/03/stupid-irresponsible-fear-mongering-in.html

Yosef Gavriel Bechhofer said...

It is difficult for me to believe that the WSJ would publish an "incredibly stupid article" (RNS) without any vetting. If that is the case, I am sure we will see a retraction and apology very shortly!

Anonymous said...

Well, I guess if the WSJ says it, it must be true, no matter how many physicians say that it's nonsense!

Do you also believe everything that you read in the NYT, or is it a special din in the WSJ?

Charlie Hall said...

The WSJ used to have much higher journalistic standards. Under the Bancroft family, a poorly researched article like this would never have seen the light of day. Rupert Murdoch has carried out his usual magic.

Charlie Hall said...

"the author of the article clearly has an ax to grind"

The author has recently written a book entitled, *The Undead: Organ Harvesting, the Ice-Water Test, Beating Heart Cadavers--How Medicine Is Blurring the Line Between Life and Death*. It gets published TOMORROW. This poorly researched essay is clearly an attempt to publicize the book and I'm not optimistic that the book is any better.

The real question is how even an experienced writer like Teresi can get a paper like the WSJ to give him what is essentially a free full page ad.

Yosef Gavriel Bechhofer said...

Dr. Hall,

I am not sure your assertions are correct.

First, you have no idea how well or poorly this article has been researched. You can only make such an assertion after you read the book.

Second, other publications have publicized Teresi's positions. See, for example:

http://www2.macleans.ca/2012/03/09/can-donating-organs-be-painful-even-after-youve-flatlined/

and other people in the medical field are at least queasy. See. for example:

http://blog.think2x.com/2012/03/11/organ-donation-check-the-selfish-bastard-box-for-me-too/

Anonymous said...

And by "in the medical field" you mean a third-year med student who admits that the entire topic is new to him. Well, I'm glad that you're relying on experts. I guess that's why you're not actually responding to any of the critiques leveled by R. Slifkin and Dr. Stadlan. After all, you have a WSJ article AND a third-year med student to rely on!

Anonymous said...

i dont even see why this article is relevant to rygb's position. if brain death is halachikly not death, then who cares if the person can feel or not?
lets say hypothetically there were incontrovertible evidence out there that a brain-dead person has absolutely no feeling/reactions. would this alter rygb's position 1 iota?
you cant use science [selectively] where it supports a halachic position, and ignore it elsewhere. doing so insults scientific inquiry and is 1/8 of 1/8 of heresy.

MIghty Garnel Ironheart said...

What's lost in all this is the definition of pain.
If a person is unconscious he feels no pain. His body may automatically respond to physical insults such as a scalpel cutting him open but in absence of higher cortical functioning that is mere automatism, not pain. Therefore the entire argument that the brain dead feel pain is not relevant here. Being unconscious they do not.

Yosef Gavriel Bechhofer said...

"And by "in the medical field" you mean a third-year med student who admits that the entire topic is new to him. Well, I'm glad that you're relying on experts. I guess that's why you're not actually responding to any of the critiques leveled by R. Slifkin and Dr. Stadlan. After all, you have a WSJ article AND a third-year med student to rely on!"

The point of the third-year medical student that struck me is the one about the place of ethics in the medical profession.

Yosef Gavriel Bechhofer said...

"i dont even see why this article is relevant to rygb's position. if brain death is halachikly not death, then who cares if the person can feel or not?"

You are indubitably correct. That is why this is not a direct challenge to Rabbi Tendler et al. Whether one agrees with them or nor, there's is a halachic position that can only be argued on halachic grounds. Rabbi Slifkin, however, is of the opinion that the moment of death is NOT a halachic issue. Accordingly, scientific issues are potentially very problematic for him.

Yosef Gavriel Bechhofer said...

"If a person is unconscious he feels no pain."

How do we know this?

Menachem Lipkin said...

Bottom line will always be: if it's immoral to give then it's immoral to receive.

I'll stick with Rav Tendler on this one.

Yosef Gavriel Bechhofer said...

It is not "immoral" to "give" - and hence not immoral to receive.