CCBI News: Organ Donation 2—Ethical Concerns, Extraordinary/Ordinary Means, Death—Organ Retrieval; Revised Guideline Canada

October 6, 2023

Dear Friends of CCBI,

Organ Donation Part Two: Ethical Concerns

Last week we reviewed basic Catholic principles on organ donation. We noted that Pope John Paul II’s standard for donation after death was that the person be certifiably dead. For this he relied on current standards of assessing brain death establishing that complete cessation of all brain functions had occurred. This standard was thought superior to declaration of death after cardiac failure, but, in turn, caused some ethical concerns brought about by the apparently ‘live’ features observed in patients declared brain dead but still on ventilators or being fed artificially.

Such observable signs include eye movements, twitching, hair growth, and so on. To the observer, these patients can seem alive, and questions were raised about possibly mistaken diagnosis, leading some people to oppose any decisions to remove means such as ventilators and artificial nutrition and hydration. Since these patients did not appear to be dead, it seemed to some they should be kept alive as long as possible.

Extraordinary and Ordinary Means

On the topic of prolonging life, Fr Leo Walsh and I wrote an article in 1994, “The House of Lords and the Discontinuation of Artificial Nutrition and Hydration: An Ethical Analysis of the Tony Bland Case,” pointing out the difference between living on one’s own capacity and being kept alive by extraordinary means. A young man, Tony Bland, had been seriously brain damaged and declared to be PVS (persistent vegetative state /post-coma nonresponsive state). As such, he had been fed by artificial means, being unable to eat, drink, or do anything. In 2004, Pope John Paul II stated that artificial nutrition and hydration were to be regarded as basic means, not extraordinary, saying: “I should like particularly to underline how the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act. Its use, furthermore, should be considered, in principle, ordinary and proportionate, and as such morally obligatory, insofar as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering.” Any case of withdrawing artificial nutrition and hydration must indicate that is fulfills the criterion of having been provided, “…insofar as and until it is seen to have attained its proper finality…,” entailing a further medical assessment of the situation.

Determining That Death Has Occurred and Retrieving Organs

Not everyone in the medical field accepts the criterion of total cessation of brain function as the only standard for establishing that death has occurred. Declaration of death after cardiac non-functioning is also accepted as a clear sign that death has occurred. This is more obvious than cessation of brain functioning in many circumstances where technology is not available, but raises ethical concerns when organ donation is to take place. Neurologically determined death was the standard by which organs could begin to be retrieved from donors in Canada prior to 2006, when donation after cardio-circulatory death (DCD)was introduced in some provinces. After this change in policy, the number of organs retrieved increased, e.g., in Southern Alberta, where the organ donation program did not begin using this procedure until 2016, showing that while the number of organs retrieved after neurological donations remains higher, those after DCD deaths are increasing.

Ethical questions about both methods persist, the most serious, of course, being the thorny problem of establishing that death has truly occurred. In Canada, following the ‘dead donor’ rule in DCD donations, there is a wait time of five minutes after the heart stops beating before proceeding to retrieval surgery. In some countries or areas, the wait time is even less because of concerns that long waits might lead to organ deterioration. While it is better for those awaiting them that organs be in the best possible condition, from a moral standpoint that is not the major determinant: the primary emphasis should be on establishing death of the donor. In cardiac death (DCD), this is complicated by the fact that there is a body of evidence showing that, although rarely, the heart can start beating again, completely unaided, seven to ten minutes after it apparently stopped.

The Archdiocese of Toronto published a guide to organ donation for Catholics in conjunction with Trillium Gift of Life in 2015 endorsing the ‘dead donor’ rule but advocating a longer wait time than the Canadian Transplantation Society’s standard, in acknowledgment of this possibility and to ensure that the donor is truly dead. Several articles have been published over the years in the medical literature on this topic, and as recently as 2020 another one, with the phrase the “Lazarus Phenomenon” in its title, advocated a wait time of twenty minutes to eliminate the possibility of auto-resuscitation, thus ensuring (at least in medical evidence to date) that the patient is certifiably dead. A longer wait time seems to be problematic in some jurisdictions, but shows that the Archdiocese’s suggested policy, written many years previously, was prudent.

Revised Guideline

The matter, however, has been brought to a different level of attention in Canada with the publication in 2023, of revised guidelines for defining death. The authors, writing in 2021 of the varying lengths of wait time after DCD had realized that, “Alignment is needed between Canadian medical guidelines for DCD where death determination definitions differ (cessation of circulation and/or brain function).” The new 2023 Clinical Practice Guideline provides “… a unified brain-based definition of death and defines the clinical criteria for its determination.” It describes death as: “The permanent cessation of brain function, observable by the absence of consciousness and brainstem reflexes including the ability to breathe independently.”

The lead author points out that until now there have been two distinct forms of death – brain death and cardiac death – but the new guidelines contain a single brain-based definition of death. He makes the important statement: “In the end it comes down to one simple truth: the only organ that we can neither artificially support nor replace is the brain. When the brain completely stops working, the person is dead.” The guideline aims to promote consistency in diagnosis and to assuage moral and legal concerns about the ‘dead donor’ requirement and should reassure potential donors about the ethics of donation as well as families who may be asked to consent to organ donation when a loved one dies.

Let’s review Pope John Paul’s definition of death noted in last week’s NEWS: “In the year 2000, in his Address to the 18th International Congress of the Transplantation Society, Pope john Paul stated: “Scientific approaches to ascertaining death have shifted the emphasis from the traditional cardio-respiratory signs to the so-called “neurological” criterion. Specifically, this consists in establishing, according to clearly determined parameters commonly held by the international scientific community, the complete and irreversible cessation of all brain activity (in the cerebrum, cerebellum and brain stem). This is then considered the sign that the individual organism has lost its integrative capacity.”

The new Canadian guideline, then, is in alignment with the Pope’s prescient conclusion in the year 2000: complete cessation of all brain functions must be observable to show the person has died. As Dr Schemie, the lead author of the new Guideline said: “When the brain stops working completely, the person is dead.” It remains to be seen whether this Guideline, if adopted nationally, will affect the number of organs donated, a serious concern for those who need transplants. It will, however, minimize ethical concerns for many others who were concerned that the ‘dead donor’ rule was not observed to the extent that it should, and who might now decide to become organ donors.

We will continue this topic in the next edition of NEWS, looking at the question of organ donation after MAID and its implications, especially for Catholics.

“The House of Lords and the Discontinuation of Artificial Nutrition and Hydration” by Moira M. McQueen and James L. Walsh (stjohns.edu)
To the participants in the International Congress on “Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas” (March 20, 2004) | John Paul II (vatican.va)
Jones, David A. “Loss of faith in brain death: Catholic controversy over the determination of death by neurological criteria.” Clinical Ethics. Volume 7, Issue 3, September 2012, Pages 133-141
Gordon et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2020)28:14
Shemie, S.D., Torrance, S., Wilson, L. et al. Heart donation and transplantation after circulatory determination of death: expert guidance from a Canadian consensus building process. Can J Anesth/J Can Anesth 68, 661–671 (2021).
Shemie, S.D., et al. “Implications of the updated Canadian Death Determination Guidelines for organ donation interventions that restore circulation after determination of death by circulatory criteria.” Can J Anesth/J Can Anesth 70, 483–557 (2023). https://doi.org/10.1007/s12630-023-02431-4

Pope Francis’ Intentions for October

For the Synod
We pray for the Church, that she may adopt listening and dialogue as a lifestyle at every level, and allow herself to be guided by the Holy Spirit towards the peripheries of the world.

Moira and Bambi