The Death Debate.

Abstract

This month’s installment of “The AJT Report” examines the ways in which a recent report on the temporary revival of cells from pig brains has underscored the need for more precise dialogue regarding brain death. We also provide a quick look at the inspiring, upcoming Summer World Transplant Games. This month’s installment of “The AJT Report” examines the ways in which a recent report on the temporary revival of cells from pig brains has underscored the need for more precise dialogue regarding brain death. We also provide a quick look at the inspiring, upcoming Summer World Transplant Games. As science advances, the transplantation community needs a more precise way to explain “brain death” to donors and their families First the reports hit Nature and then the general media: Scientists were able to “revive” dead pig brains and “keep them alive” for 10 hours after death.1Vrselja Z Daniele SG Silbereis J et al.Restoration of brain circulation and cellular functions hours post-mortem.Nature. 2019; 568: 336-343Crossref PubMed Scopus (115) Google Scholar In actuality, the report demonstrated some remnant cellular functions persisted when brains of dead pigs underwent ex vivo perfusion. The news reverberated throughout the lay community, sparking questions over its implications for transplantation. Does the scientists’ work undermine the Dead Donor Rule, a standard that anchors the field’s ethical foundation of voluntary deceased organ donation? Plainly stating that vital organs should only be transplanted from dead patients, the Dead Donor Rule underscores the transplantation community’s commitment to respect persons and human life. However, this newly reported science had some wondering: If dead pigs are not dead, are dead patients dead? The casual reader may easily imagine that the brains extracted from these dead pigs were at that point “brain dead,” and that the revival of the brains was the porcine equivalent of reversing human brain death. “Sometimes language is so important, especially in this field of organ transplantation,” says Jim Gleason, president of Transplant Recipients International Organization in Beverly, New Jersey. He encourages others in the transplantation community to think carefully about the actual meaning of “brain death” and to employ precise language when discussing it. Fear of death, particularly fear of a premature, mistaken declaration of death, pervades humanity, says James F. Childress, PhD, professor of ethics at the University of Virginia in Charlottesville. Perhaps because of this fear, death has historically tended to be up for debate, dramatized in macabre works by the likes of authors Edgar Allen Poe (1809–1849) and Bram Stoker (1847–1912), who leveraged the technical ambiguity of life versus death to great effect. Decay is the only reliable indicator of the death of a system, as Dr. Childress points out. However, the transplant community cannot wait for the unfolding of this natural process, and the resulting tension between the human need for certainty and the imperative to save lives fuels a fear that organs may be removed following a mistaken declaration of death. Thus, explains Dr. Childress, the new data raise concerns for the transplantation community. The question is, he says, “If we have the public discourse, will we damage the public trust that is important for organ donation?” In other words, in the absence of a clear line between life and death, will more people say no to organ donation?KEY POINTS•A recent report on the temporary revival of brain cells from dead pigs has confounded the usual definition of brain death.•Some within the transplantation community are concerned that the common human fear of “mistaken death” will discourage people from becoming donors.•A thorough, established protocol for determining brain death still preserves the viability of donor organs.•It is important for physicians to be precise when explaining the irreversibility of brain death to donors and families, including awareness of new developments in neurobiology that might complicate discussions about death. •A recent report on the temporary revival of brain cells from dead pigs has confounded the usual definition of brain death.•Some within the transplantation community are concerned that the common human fear of “mistaken death” will discourage people from becoming donors.•A thorough, established protocol for determining brain death still preserves the viability of donor organs.•It is important for physicians to be precise when explaining the irreversibility of brain death to donors and families, including awareness of new developments in neurobiology that might complicate discussions about death. The Dead Donor Rule assumes that it is possible to reliably determine whether a person is living or dead. It also assumes that once an individual is declared dead, they cannot be harmed. When this assumption is applied, a declaration of death by an appropriate medical professional changes an individual’s legal status. The declaration also serves a gatekeeping function for organ donation. The inclusion of brain death as a subset of death has increased the number of potential organ donors and improved the viability of donated organs. The new pig data, however, have left some people wondering whether brain death can or should still be used in a determination of death, and have added fuel to the debate—ongoing since its adoption in the 1970s—about the ethics of the rule. (The brain death concept was partly developed so that patients with serious neurological injuries could be defined as dead before cardiopulmonary arrest. Thus organs could be removed before they were damaged by oxygen loss. Controversy over the rule has continued, and a number of scientists/ethicists have always taken issue with the neurological criteria of death.) Robert Veatch, PhD, senior research scholar and professor emeritus of medical ethics at Georgetown University in Washington, DC, contends that the new data do not affect our understanding of brain death. “I think it is scientifically very interesting, but single cells don’t count as activity in the brain for the purposes of death pronouncement,” he says. Moreover, he adds that even if it were possible to somehow reanimate more than individual cells, such an accomplishment would not be the equivalent of recreating brain function because even individuals who have been declared brain dead can have nests of cells that may still be receiving blood and functioning. “Those of us in the field know that the implications are trivial at best,” emphasizes Dr. Veatch. “It certainly won’t change the way we pronounce brain death.” Physicians have an established protocol for determining death: Multiple physiological tests are conducted over the course of hours before a physician may declare a loss of brain function. These tests require the physician to rule out hypothermia or any other potentially confounding condition that might be reversed. Once the patient is declared brain dead, the death is, by definition, physiologically irreversible. It is only at that point that a physician can make a declaration of death and that organs can be removed. Even if all the cells in the brain could be reanimated, the new technology used on pig brains would have no effect on the declaration of brain death, Dr. Veatch says, as neural activity requires coordinated network communication, not single cell survival. Therefore, the recent pig study, while fascinating, is irrelevant to transplant. Dr. Veatch also points out that while brain death can be deemed physiologically irreversible, it can also be deemed morally irreversible, and/or legally irreversible, as in instances where a patient’s family has refused further intervention. In such situations it might be theoretically possible to reverse some elements of brain function, but to do so would be illegal and immoral. He gives as an example the patient in a permanent vegetative state: Once the ventilator is withdrawn and immediately after brain function is lost, it would be theoretically possible to reverse function loss by pumping blood into the brain. However, if that patient or the patient’s family has ordered the medical team not to resuscitate and thus not restart the ventilator, the patient at this point would be deemed to have morally and legally irreversible brain damage. Dr. Veatch emphasizes that even if it became possible in the future for brain cells to be restarted after loss of functioning, this option would not even be a consideration when a do-not-resuscitate order is in effect. He adds that it is difficult to envision a circumstance in which family members who have decided to remove a ventilator then change their minds and decide to resuscitate their loved one’s brain. The fact remains, points out Dr. Childress, that the new findings, while irrelevant to bioethicists familiar with transplantation, may be confusing to families facing a declaration of brain death for a loved one. In such cases, it may be necessary to remind families that the transplant community has the technology and ethical framework to determine when a patient is dead and to do so within a time frame that enables the organs to still be viable. In essence, the new report has not changed the standing of the Dead Donor Rule. However, the discussion it has launched, and the resulting public discourse, could have serious implications for the transplant community. The facts and misconceptions surrounding the matter of brain death should be communicated to potential donor families in precise and informative language. According to Dr. Veatch, this means that the transplant community should acknowledge the new data to patients but also explain to them that the new pig technology does not change the way we currently determine brain death or the fact that brain death is, by definition, irreversible. The World Transplant Games Federation has promoted education around transplantation for more than 35 years through medical research, conferences and a culture of physical well-being perhaps best exemplified by its Summer and Winter World Transplant Games. This summer the games move to the twin cities Newcastle/Gateshead in the United Kingdom. From August 17 to 24, participants and fans will gather at indoor and outdoor venues within the very heart of the cities to cheer on competitors vying for titles in archery, badminton, cycling and more. The Games are a cultural and social program as well as an athletic event, spotlighting the benefits of transplantation in this unique arena. Entry is open to recipients of life-supporting allografts and hematopoietic cell transplants from other individuals or species, and competitors must be medically fit, have been transplanted for at least one year with stable graft function and have trained for the events in which they are entered. Children, teenagers and adults compete by gender in multiple age groups, and all the athletes are on immunosuppressive drug therapies. Donor families and living donors are also welcome to participate in an array of sporting events. The first competitive sporting event for transplant recipients took place in England in 1978 and included approximately 100 competitors from the United Kingdom, France, Germany, Greece and the United States. This year’s games are expected to include 1,500 competitors from 69 countries. To learn more, visit https://wtgf.org.