Wednesday, August 8, 2012

Why I'm Not an Organ Donor

In the horrific 1978 scifi thriller,   'COMA'    starring Genevieve Bujold, Michael Douglas and Richard Widmark, specific patients (often younger) are directed for surgery into Room 'OR-8' where instead of getting regular anesthesia (and unbeknownst to the anesthesiologist) a line bearing CO (carbon monoxide) gas is fed into the system to elicit brain death. Thus, all such earmarked patients end up as "goobers" who are later shipped to a special facility where they're kept alive for later harvesting of their organs....mainly for rich creeps who arrive at a weekly auction to bid on which organs they want.

The basic premise in the film is that a certain extended brain death is sustained, and the organs, body kept otherwise alive, until the organs get auctioned off.

This scenario is intriguing because it brings to mind the recent book by Dick Teresi: 'The Undead: Organ Harvesting, the Ice Water Test, Beating Heart Cadavers - How Medicine is Blurring the Line Between Life and Death' (Pantheon Books, 2012).  The book covers a lot of critical ground and key points that bear on medical ethics and the definition of "death" - so I don't want to ruin it for any blog readers who may wish to purchase it or borrow it.  Hence, I will briefly give just an outline.

But imagine this if you can: you're being operated on and something goes wrong with the anesthesia, and you end up brain dead and hence a "BHC" (beating heart cadaver). Your EEG may be flat, but lo and behold, you can still urinate, feel pain (as betrayed by spiking blood pressure when the Lebsche knife splits open the sternum to open the chest cavity for organ extraction) and your other organs, tissues continue to function. In addition, if allowed to persist in that state long enough, body temperature will be maintained (albeit at a lower level), wounds will continue to heal, cellular wastes will continue to be eliminated, detoxified and if pregnant, you will gestate. Also, an immature (i.e. brain dead child)  body will mature sexually and grow proportionately.

In other words, by all indicators, the person is still alive, or at least as alive as the patients gassed by CO in 'Coma', and whose organs are then harvested. What gives? Well, what gives is that brain death may not be a sufficient and proper standard to assess or determine the stage at which organs ought to be harvested. Perhaps a more stringent standard needs to be brought back, say the total and prolonged - e.g. > 1 hr. - cessation of heart beat, as in the olden years.

What changed? Well, as the authors observe, an "Ad hoc committee' based at Harvard, came up with a set of criteria to redefine death away from heart failure. The reason was that so many cases were occurring in which patients did find themselves brain dead, so....what to do with this husk of a formerly conscious or potentially conscious person?  The new Harvard ad hoc criteria changed all that and soon became the new standard for declaring people dead, as manifested by being legally codified in all fifty states within only 13 years of the issuance.

Why conflate death with brain death? Because it was believed and accepted, in the philosophic (not biological ) sense, that a kind of "personhood" actually defined life. If then there was brain death, that personhood was no longer evident, hence for all practical purposes the former person had become something less than human....or a "goober" to use the term of the insensitive docs in Coma, who did the harvesting.  If a "goober" and hence no longer a "person", his organs could be harvested at will, never mind the possibility of not being technically dead (meaning all life processes have ceased and decay is imminent.)

Dr. Alan Shewmon, cited in the book, and a neurologist at UCLA, dismisses this idead of "personhood" as any substantive idea. After all, we do not ascribe a special "lizard -hood" to lizards, or "monkey-hood" to monkeys, so why attach personhood to humans? It is another case of human exceptionalism not supported by any objective or empirical evidence. Shewmon's point is that like other animals humans should be judged biologically on whether they're dead or alive. And for sure, a spiking blood pressure, say in response to the driving force of a Lebesche knife on the sternum,  is not an auspicious sign of genuine death! (Critics cited insist the Harvard group was obsessed with freeing up organs for transplant, hence deliberately confected a lower threshold, detached from actual, biological death.)

This may also be one reason, as the authors note, that in the European system a general anesthesia is administered to BHCs if any organ harvesting is done.....just in case there is some residual consciousness in the body that is aware ...if only at a rudimentary level...and feels pain.

The other problem of Shewmon and others (e.g. Dr. Robert Truog, in Anesthesiology, The Journal of the American Society of Anesthesiologists) is that the brain death aficionados have been proven wrong numerous times, especially in terms of claims - such as that "all bodily functions ought to cease within hours of brain death". Well, they didn't, so that the claim was extended to days, then weeks. (Shewmon documented 150 cases of brain dead patients whose bodies did not disintegrate after a week's time, and in one case a patient survived 20 years after brain death before succumbing to cardiac arrest.)

Rightfully, one organ harvest surgeon stated flatly he prefers not to harvest any organs unless the body - actually a real cadaver - is stone cold. It appears others, in the interest of all important "efficiency" are more interested in grabbing organs as quickly as possible because the longer hospital resources must be used to keep these patients alive, the lower the profit margins. As the authors note, the notion that body parts are harvested from dead, unfeeling corpses may sound neat, but the reality is often messier and a lot more complicated.

Until it becomes much less complicated, I don't volunteer any organs for organ donation, as when I sign up for photo ID. (And certainly so long as no general anesthesia is used while harvesting!) Further, I do not wish to be even  partially aware if my sternum is being split open and then splayed apart by a retractor to reach in and grab lungs, liver or whatever.

Other people can, of course, make whatever choice they deem meets their own expectations and values. But I am keeping my organs at least until the profit motive (and cruel efficiency)  is less of a driver for the harvesters!

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