From Dr.D.W.Evans
01223 356740 27 Gough Way
Cambridge
CB3 9LN
Ms. Patricia Fraser
Editorial Secretary, BMA Medical Ethics Committee
BMA House, Tavistock Square
London WC1H 9JP 1st July 2000
Dear Ms. Fraser,
Organ Donation in the 21st Century
Time for a consolidated approach
Thank you for sending me a copy of your committee’s recent publication, in the Introduction to which the hope is expressed that it will stimulate wide-ranging debate. I am therefore encouraged to make the following observations, particularly in respect of the highly contentious statements to be found under “Addressing common concerns” on page 8.
It is there stated that “it is unfortunate that” the term (brain stem death) has been taken to imply a ‘special’ form of death rather than simply its clearest manifestation”. It is then claimed as a fact that “the brain is no longer capable of sending or receiving the relevant information via the brain stem and thus recovery is impossible.” This statement not only perpetuates the confusion between mortal (brain) damage and death itself but is challengeable on at least two other grounds, a) because not all of the brain stem is dead when the “brain stem death” criteria are satisfied in common practice1, and b) because, even if it were, the higher brain could still receive olfactory and visual information via the first and second cranial nerves whose pathways to the cerebral cortex do not, as any neurologist or anatomist will tell you, pass through the brain stem. Perhaps your committee considers such information - which might result in nightmarish visually-provoked experiences (for it is possible that some form of consciousness might be preserved2) - not “relevant” for some reason, perhaps because the patient could not show response.
The suggestion that “Death confirmed by brain stem tests should therefore be seen as the clearest indication of what is commonly understood as ‘death’, more so than the stopping of the heart, or of breathing, both of which can, in some circumstances, be reversed” is so obviously non-sensical that I fear it will destroy your committee’s credibility in the eyes of intelligent, well-informed, readers. The dimension which is missing is time. It is the final cessation of the flow of oxygenated blood around the body, and particularly through the brain, which guarantees that all brain function will be lost, never to return, and therefore justifies a diagnosis of death. That is the time-honoured, and still the only safe and scientifically-based, criterion. Please note that it is the circulation which is crucial and not the heartbeat per se. The heart can be stopped temporarily and its function subsumed by other means of pumping blood while it is repaired, restarted or replaced. The development of techniques for life-support while the heart is not pumping has allowed us to resuscitate some whose brain function has thus been safeguarded while the heart has been in ventricular fibrillation or asystole; everyday open-heart surgery is, of course, dependent on them. Perhaps I should mention that, in the course of my professional career, I have attended several hundred patients in cardiac arrest - not to diagnose death just because there had been no heartbeat for several minutes but to attempt resuscitation. In those cases, I (sometimes very reluctantly) diagnosed and certified death only when I was convinced that the cardiac arrest was indeed final. The omission of that crucially important word from facile “definitions” of “cardiac death” is dangerously misleading. I am bound to wonder if some members of your committee have not been so misled. The alternative explanation for the persistent misuse is one that I hardly like to entertain. It involves an intention to mislead and manipulate the thought of those less expert in clinical matters and who may, therefore, be prepared to take on trust the pronouncements of a body backed by the BMA.
It cannot reasonably be maintained that “Death confirmed by brain stem tests” is death. “Brain stem death” is no more than a pre-mortal clinical syndrome. The alleged inevitability of its progression to death (apart from when vital organs are removed in that state, obviously) has never been prospectively validated2 and recent advances raise the possibility of survival in some cases previously considered doomed3. It is not brain death, as the RCP Working Party admitted in 1995, and neither is it brain stem death in the full and factual sense. It is high time that the public were allowed to know these facts - given to them fully and frankly and in terms which they can understand. If they then volunteered removal of their organs (or their children’s organs) in that state it might be thought that their consent was valid (if not obtained under duress or more subtle pressure). But evisceration before death would not, think, be permitted under the present Law. Perhaps, in our modern utilitarian society, you should be campaigning for a change in the Law to permit the removal of organs for transplantation from the dying if all the interested parties fully understood and agreed. In the long run, that may yield more donors than the continuing efforts to deceive the public (and professions) about death. Do not underestimate the common recognition of death as a natural fact - nor the damage to trust in the medical profession (upon which good clinical practice depends) which will result from continuing deception in the interest of a very small element of surgical practice.
You say (page 16) that “None of the major religions represented in the UK are opposed to organ donation”. In the light of what I have written above, you will understand my suspicion that at least some of the religious leaders who have, perhaps tacitly, indicated approval have not fully understood the salient facts.
Yours sincerely,
David Wainwright Evans (Retired cardiologist)
References
1. Evans DW & Hill DJ. The brain stems of organ donors are not dead. Catholic Medical
Quarterly 1989; 40: 113 - 121.
And see several other subsequent publications documenting persisting brain stem functions, particularly blood pressure and heart-rate control.
2. Young PJ & Matta BF. Anaesthesia for organ donation in the brainstem dead - why bother?
Anaesthesia 2000; 55 : 105 - 6.
And see related correspondence, p. 590.
3. Coimbra CG. Implications of ischemic penumbra for the diagnosis of brain death. Brazilian J Med . Biol Res 1999; 32 : 1479 - 87.