Mar 2005 (CWR) – On February 3-4, the Pontifical Academy of Sciences, in cooperation with the World Organization for the Family, hosted a meeting at the Vatican entitled “The Signs of Death.” This essay is based on the papers that were submitted to the Pontifical Academy as well as the discussions that took place during those two days. The meeting was convened at the request of Pope John Paul II (bio – news) to re-assess the signs of death and verify, at a purely scientific level, the validity of brain-related criteria for death, entering into the contemporary debate of the scientific community on this issue. In a message to the Pontifical Academy of Sciences, made public at the February meeting, the Holy Father said that the Church has consistently supported “the practice of transplanting organs from deceased persons.” However, he cautioned that transplants are acceptable only when they are conducted in a manner “so as to guarantee respect for life and for the human person.” The Pope cited his predecessor, Pope Pius XII, who said that “it is for the doctor to give a clear and precise definition of death and of the moment of death.” He encouraged the Pontifical Academy to pursue that task, promising that scientists could count on the support of Vatican officials, “especially the Congregation for the Doctrine of the Faith.”
In his presentation to the Pontifical Academy, Robert Spaemann-a noted former professor of philosophy from the University of Munich-cited the words of Pope Pius XII, who declared that “human life continues when its vital functions manifest themselves, even with the help of artificial processes.” Professor Spaemann observed: “The cessation of breathing and heartbeat, the ‘dimming of the eyes,’ rigor mortis, etc. are the criteria by which since time immemorial humans have seen and felt that a fellow human being is dead.” But the Harvard criteria “fundamentally changed this correlation between medical science and normal interpersonal perception.” As he put it: Scrutinizing the existence of the symptoms of death as perceived by common sense, science no longer presupposes the “normal” understanding of life and death. It in fact invalidates normal human perception by declaring human beings dead who are still perceived as living. The new approach to defining death, the German scholar continued, reflected a different set of priorities: It was no longer the interest of the dying to avoid being declared dead prematurely, but other people’s interest in declaring a dying person dead as soon as possible. Two reasons are given for this third party interest: 1) guaranteeing legal immunity for discontinuing life-prolonging measures that would constitute a financial and personal burden for family members and society alike, and 2) collecting vital organs for the purpose of saving the lives of other human beings through transplantation. These two interests are not the patient’s interests, since they aim at eliminating him as a subject of his own interests as soon as possible. The arguments against the use of “brain death” as a determination of death are being made, Spaemann noted, “not only by philosophers, and, especially in my country, by leading jurists, but also by medical scientists.” He quoted the words of a German anesthesiologist who wrote, “Brain-dead people are not dead, but dying.”
DEFENDING THE CRITERIA
Some participants in the February meeting defended the use of the “brain death” criteria. Dr. Stewart Youngner of Case Western University in Ohio admitted that “brain dead” donors are alive, but argued that this should not prove an impediment to the harvesting of their organs. His reasoning was that there is such poor “quality of life” in the “brain dead” patient that it would be more beneficial to harvest their organs to extend the life of another than to continue the life of the organ donor. Dr. Conrado Estol, a neurologist from Buenos Aires, explained the steps that should be followed in determining the “brain death” of a prospective organ donor. Dr. Estol, who is strongly in favor of harvesting human organs to extend the life of other patients, presented a dramatic video of a person diagnosed as “brain dead” who attempted to sit up and cross his arms, although Dr. Estol assured the audience that the donor was a cadaver. This produced an unsettling response among many participants at the conference. A French transplant surgeon, Dr. Didier Houssin, acknowledged the difficulties that arise because of the discrepancies between the different criteria for brain death. He observed that “death is a medical fact, a biological process, and a philosophical question, but it is also a social fact. It would be difficult for a society to admit that a man could be said alive in one place and dead in another place.” However, as a proponent of transplants, he said that it is important for society to trust doctors. Another French physician, Dr. Jean-Didier Vincent of the Institut Universitaire, emphasized that a “brain dead” person has suffered complete and irreversible destruction of the brain. Dr. Vincent was questioned closely about the case of a pregnant women, diagnosed as brain-dead, who continues her pregnancy while on a life-support system, even producing breast milk for her unborn child. He admitted that the mother produces milk, but regards that production as an inhibited mechanical reflex rather than a sign of enduring human life. When reminded that the production of breast milk results from the signal sent from the anterior lobe of the pituitary that stimulates the secretion of milk, and possibly breast growth, thus requiring a functioning brain, he replied that there could be some minimal hormonal production in the brain.
THE APNEA TEST
Dr. Hill recalled that the earliest attempts at transplanting vital organs often failed because the organs, taken from cadavers, did not recover from the period of ischemia following the donor’s death. The adoption of brain-death criteria solved that problem, he reported, “by allowing the removal of vital organs before life support was turned off-without the legal consequences that might otherwise have attended the practice.” While it is remarkable that the public has accepted these new criteria, Dr. Hill remarked, he attributed that acceptance in large part to the favorable publicity for organ transplants, and in part to public ignorance about the procedures. “It is not generally realized,” he said, that life support is not withdrawn before organs are taken; nor that some form of anesthesia is needed to control the donor whilst the operation is performed.” As knowledge of the procedure increases, he observed, it is not surprising that-as reported in a 2004 British study-”the refusal rate by relatives for organ removal has risen from 30 percent in 1992 to 44 percent.” Dr. Hill also suggested that when relatives see with their own eyes the evidence that a potential organ donor is still alive, they harbor enough doubts so that they are not ready to consent to the organ removal. In the United Kingdom, Dr. Hill reported, there is mounting pressure for individuals to sign, and always carry with them, donor cards authorizing doctors to use their vital organs. Today only about 19 percent of the country’s people have registered as organ donors, but vehicle-registration forms, driver’s-license applications, and other public documents provide “tick boxes” allowing citizens to give this advance directive; even children are encouraged to sign. All such documents specify that organs may be harvested only “after my death,” but there is no definition of what constitutes “death.” Again, Dr. Hill remarked, the acceptance of transplants hangs on the public’s lack of understanding about the procedure. And yet, he pointed out, “For any other procedure, informed consent is required, but for this most final of operations no explanation nor counter-signature is required, nor is the opportunity given to discuss the question of anesthesia.” Bishop Fabian Bruskewitz of Lincoln, Nebraska, addressed the issue of the donor’s consent. “As far as I know,” he told the Pontifical Academy, “no respectable, learned, and accepted moral Catholic theologian has said that the words of Jesus regarding laying down one’s life for one’s friends (John 15:13) is a command or even a license for suicidal consent for the benefit of another’s continuation of earthly life.” The bishop went on to observe that current technology enables doctors only to monitor brain activity “in the outer 1 or 2 centimeters of the brain.” He asks: “Do we have then, moral certitude in any way that can be called apodictic regarding even the existence, much less the cessation of brain activity?” From the perspective of Catholic moral teaching the bishop said: The dignity and autonomy of a human being-whether zygote, blastocyst, embryo, fetus, newborn, infant, adolescent, adult, disabled or handicapped adult, aged adult, adult in a comatose or (so-called) persistent vegetative state, etc.-are viewed, as they have been viewed throughout the history of the Catholic Church, as worthy of respect and entitled to protection from untoward human intervention effecting the termination of human life at any of those stages. In light of the serious questions about the validity of the “brain death” criteria, Professor Josef Seifert from the International Academy of Philosophy in Liechtenstein argued that medical ethicists should invoke the true and evident ethical principle (emphasized by the whole Church tradition of moral teachings), that “even if a small reasonable doubt exists that our acts kill a living human person, we must abstain from them.”
01. On the one hand the Church recognizes, consistent with her tradition, that the sanctity of all human life from conception to natural end must absolutely be respected and upheld. On the other hand, a secular society tends to place greater emphasis on the quality of living. 02. The Catholic Church has always opposed the destruction of human life before being born through abortion and she equally condemns the premature ending of the life of an innocent donor in order to extend the life of another through unpaired vital organ transplantation. “It is morally inadmissible directly to bring about the disabling mutilation or death of a human being, even in order to delay the death of other persons.” “It is never licit to kill one human being in order to save another.” 03. “Nor can we remain silent in the face of other more furtive, but no less serious and real forms of euthanasia. These could occur for example when, in order to increase the availability of organs for transplants, organs are removed without respecting objective and adequate criteria which verify the death of the donor.” 04. “The death of the person is a single event, consisting in the total disintegration of that unitary and integrated whole that is the personal self. It results from the separation of the life-principle (or soul) from the corporal reality of the person.” Pope Pius XII declared this same truth when he stated that human life continues when its vital functions manifest themselves even with the help of artificial processes. 05. “Acknowledgement of the unique dignity of the human person has a further underlying consequence: vital organs which occur singly in the body can be removed only after death-that is, from the body of someone who is certainly dead. This requirement is self-evident, since to act otherwise would mean intentionally to cause the death of the donor in disposing of his organs.” Natural moral law precludes removal for transplantation of unpaired vital organs from a person who is not certainly dead. The declaration of “brain death” is not sufficient to arrive at the conclusion that the patient is certainly dead. It is not even sufficient to arrive at moral certitude. 06. Many in the medical and scientific community maintain that brain-related criteria for death are sufficient to generate moral certitude of death itself. Ongoing medical and scientific evidence contradicts this assumption. Neurological criteria alone are not sufficient to generate moral certitude of death itself, and are absolutely incapable of generating physical certainty that death has occurred. 07. It is now patently evident that there is no single so-called neurological criterion commonly held by the international scientific community to determine certain death. Rather, many different sets of neurological criteria are used without global consensus. 08. Neurological criteria are not sufficient for declaration of death when an intact cardio-respiratory system is functioning. These neurological criteria test for the absence of some specific brain reflexes. Functions of the brain not considered are temperature control, blood pressure, cardiac rate and salt and water balance. When a patient on a ventilation machine is declared “brain dead,” these functions not only are present but also are frequently active. 09. The apnea test-the removal of respiratory support-is mandated as a part of the neurological diagnosis and it is paradoxically applied to ensure irreversibility . This significantly impairs outcome, or even causes death, in patients with severe brain injury. 10. There is overwhelming medical and scientific evidence that the complete and irreversible cessation of all brain activity (in the cerebrum, cerebellum, and brain stem) is not proof of death. The complete cessation of brain activity cannot be adequately assessed. Irreversibility is a prognosis, not a medically observable fact. We now successfully treat many patients who in the recent past were considered hopeless. 11. A diagnosis of death by neurological criteria alone is theory, not scientific fact. It is not sufficient to overcome the presumption of life. 12. No law whatsoever ought to attempt to make licit an act that is intrinsically evil. “I repeat once more that a law which violates an innocent person’s natural right to life is unjust and, as such, is not valid as a law. For this reason I urgently appeal once more to all political leaders not to pass laws which, by disregarding the dignity of the person, undermine the very fabric of society.” 13. The termination of one innocent life in pursuit of saving another, as in the case of the transplantation of unpaired vital organs, does not mitigate the evil of taking an innocent human life. Evil may not be done that good might come of it.
Signatories: J.A. Armour, physician, University of Montreal Hospital of the Sacred Heart, Montreal, Quebec. Fabian Bruskewitz, Bishop of Lincoln, Nebraska Paul A. Byrne, past president, Catholic Medical Association, US. Pilar Mercado Calva, professor, School of Medicine, Anahuac University, Mexico. Cicero G. Coimbra, professor of Clinical Neurology, Federal University of Sao Paolo, Brazil. William F. Colliton, retired professor of Obstetrics and Gynecology George Washington University Medical School, Virginia. Joseph C. Evers, clinical associate professor of Pediatrics, Georgetown University School of Medicine, Washington, DC. David Hill, emeritus consultant anesthetist, at Addenbrooke’s Hospital, and associate lecturer, Cambridge University, England. Ruth Oliver, psychiatrist, Kingston, Ontario. Michael Potts, head of Religion and Philosophy Department, Methodist College, Fayetteville, North Carolina. Josef Seifert, professor of Philosophy at the International Academy of Philosophy, Vaduz, Liechtenstein; honorary member of the Medical Faculty of the Pontifical Catholic University of Chile in Santiago, Chile. Robert Spaemann, professor emeritus of Philosophy, University of Munich, Germany. Robert F. Vasa, Bishop of the Diocese of Baker, Oregon. Yoshio Watanabe, consultant cardiologist, Nagoya Tokushukai General Hospital, Japan. Mercedes Arzú Wilson, president, Family of the Americas Foundation and World Organization for the Family.
 Catechism of the Catholic Church 2296.  Pope John Paul II, Message for World Day of the Sick, February 4, 2003.  Evangelium Vitae 15.  Pope John Paul II. Address to the 18th International Congress of the Transplantation Society, August 29, 2000.  ibid.  Jeret JS, Benjamin JL. Risk of hypotension during apnea testing. Arch. Neurol.1994, 516(6). 595-599.  Coimbra, C. The apnea test, a bedside lethal disaster, to avoid legal disaster in the operating room. Presented at the Pontifical Academy of Sciences on February 3, 2005.  Evangelium Vitae 90.