A Grim Harvest

Upon learning of his son’s fatal heart disease, a father arranges to donate his own heart in order to save his son’s life. The surgery will result in his death; his son will learn of it only after the fact. Should the hospital administrators allow the surgery to proceed?

Ethicist Paul Ramsey proposed this scenario for medical practitioners in 1970, warning, “This case, or one like it, will happen one day.”

“May it never be!” we rejoin, now as then. But the preparations for it are already underway.

In the practice of critical care medicine, we sometimes end up caring for patients who have suffered severe illness or injury and are deteriorating toward brain death. When that happens, in current practice, doctors change their orientation. Instead of aiming to ease and extend the person’s life, they begin to think about identifying the moment that the patient has passed the legal threshold of death. The physician adopts an approach previously unknown to medical practitioners, turning his attention from the patient for whom he is caring to a vast number of patients whose travail is great, though they are not specifically his patients. The weighted hour of death, with all its cultural and religious ritual, has been tied to the acquisition of transplantable organs.

With the patient redefined as a repository of life-saving goods, much hangs on the anticipation of death, and on how death is determined. It was, after all, in the immediate aftermath of the first successful human heart transplant that the medical profession recognized the need to establish criteria to pronounce “brain death,” to be used in certain cases in place of traditional “cardiorespiratory” criteria for death. This effort led to the Uniform Declaration of Death Act (UDDA) in 1981, which established in law that death may be diagnosed by either traditional cardiorespiratory or neurologic criteria. This revision in medical understanding arises from a simple fact: Because of breakthroughs in organ transplantation, the lives of some now depend upon the deaths of others. When and how an individual dies determines whether and how needy patients survive.

For whom, then, is the physician to care in this sad hour? The terminal patient in front of him, or the many in the community at large waiting for life-sustaining organs?

The interests of the individual patient have long been guarded by the tenets of the Hippocratic tradition, which balance patient autonomy and physician beneficence. They have also, at least so far, been maintained by ethical guidelines of the United Network for Organ Sharing. The UDDA has, in construct and in code, respected both dying patient and potential organ recipient. Current brain death, procurement, and transplantation practices, I believe, are sound.

But a significant gap between transplantable organ supply and demand remains, and it threatens the long-standing moral constraints on turning patients into organ sources.

The pressure to close the gap is strong, and it has led to a variety of proposals being put forward in recent years. Some take a fairly cold and pragmatic approach to organ harvesting. New York City emergency medicine specialist Stephen Wall has endorsed a program in which patients who suffer trauma or cardiac arrest are afforded some resuscitation efforts, but if these fail and the patient is pronounced dead (as determined by a remote authority), CPR will be continued—on the dead patient—until a relative or other surrogate can give consent for organs to be harvested. Going a step further, Oxford philosopher and bioethicist Julian Savulescu recommends organ conscription, a policy that ascribes the authority to assign all organs of the dead or dying to the state and thus obviates the need for consent.

Measures such as these are not likely to be adopted as long as they appear to violate individual autonomy, which our culture prizes and which is the prime argument for physician-assisted suicide. But they change the climate of opinion regarding the handling of terminally ill patients. They favor the creation of new insidious possibilities, which, in fact, now loom on the horizon.

Robert Veatch, professor emeritus of ethics at Georgetown University, wants to expand the criteria of brain death so that they include the loss of overt cognitive function. He defines this “higher brain criterion” for death as loss of personhood. Veatch would declare dead anyone who is persistently “vegetative,” who, despite being in a deep coma, continues to breathe and have sleep-wake cycles, and who actually may be aware of external stimuli, though it may be difficult to detect their awareness except by complex neurophysiologic imaging. When consent is given by advance directive or by a surrogate, these patients’ organs could be procured for transplantation.

Harvard professor Robert Truog gets around the autonomy objection by making death-by-donation itself consent- and autonomy-driven. A patient or his surrogate may electively end his life by permitting the procurement of vital organs, under anesthesia, in the operating room. It bears repeating: Death, voluntary and physician-mediated, will result from organ procurement. Savulescu takes the approach further, prescribing specific techniques by which death may be hastened by physicians so that they can procure the optimal number of viable organs. This is not hypothetical. The practice of donation euthanasia is alive and well in Europe.

In spite of obvious religious objections to these proposals, considerable scholarship across denominational and religious lines endorses the practice of organ donation, procurement, and transplantation. Many Christians in good conscience affirm this practice once a person’s death has been established by traditional circulatory or whole-brain criteria.

Others, however, agree with Veatch’s “higher brain” model. Oxford professor of moral philosophy Jeff McMahan denies that personhood requires an organism. The body, on his construct, is dispensable if the capacity for rational thought is gone. John Lizza, professor of philosophy at Kutztown University of Pennsylvania, agrees with McMahan’s dualism, asserting that personhood itself is distinct from the physical body or organism. The organism may continue to live, but the person is dead. For these thinkers, an otherwise healthy body without a “person” housed within it is not a form of life worth preserving. It is a thing with human parts, which are now understood as under-utilized assets to be reallocated.

In accord with the spirit of our age, advocates of death-by-donation establish individual autonomy and consent as the driving principle for decision-making. Bioethicist Ruth Macklin argues that the sole criterion for human dignity is autonomous choice; Savulescu believes that donation euthanasia improves autonomy and reduces the chances of suffering near death. Edmund Pellegrino explains clearly and simply the sacrilege involved in such an approach: “In ethics generally and medical ethics in particular, autonomy, freedom, and the supremacy of private judgment have become moral absolutes. On this view, human freedom extends to absolute mastery over one’s life, a mastery which extends to being killed or assisted in suicide so long as these are voluntary acts.” He continues, “For the Christian, this is a distorted sense of freedom that denies life as a gift of God over which we have been given stewardship as with other good things.”

Will Christians be tempted to embrace Truog’s euthanasia agenda? Sadly, some will. A patient who is dying may see himself as serving his fellow man by volunteering for suicidal donation. He might understand his act as the natural extension of the current practice of altruistic kidney donation. Some will undoubtedly argue that organ donation by euthanasia will give one’s suffering and death redemptive value. This is the line of thinking of many medical professionals and ethicists.

Just a few years ago, physician-assisted suicide was performed by malcontent retired pathologist Jack Kevorkian in makeshift vans, and the man and the practice were widely condemned. Euthanasia and physician-assisted suicide were anathema to the medical community and to the state. They were regarded as practices of a pagan past from which the Hippocratic tradition, assimilated into and reshaped by Judeo-Christian ethical thought, rescued humankind for two millennia. But the scientific and technological advances of the twentieth century, along with the growth of corporate medicine, have been accompanied by a gradual deterioration of the patient-physician relationship. The physician’s ability to experience the afflictions of his patients personally and empathetically has been truncated.

The growing distance between doctors and patients allows for the expansion of the utilitarian approach that sees patients as organ donors, not individuals in need of care. Meanwhile, patients’ rights advocacy groups such as Compassion and Choices have championed the choice of suicide for the horribly ill. Riding the publicity wave of Brittany Maynard, a young woman who suffered much and became the human face of the death-with-dignity movement, they have redefined compassion as respect for a patient’s autonomous determination of the time, location, and method of death.

Recently, Kathryn Tucker, chief legal counsel for Compassion and Choices, published her group’s assisted suicide guidelines in Chest, one of our premier critical care journals. Truog, himself an intensive care practitioner, has published guidelines on state-of-the-art end-of-life care in Critical Care Medicine. A Dutch “practical manual” for organ procurement following euthanasia has appeared last year in The American Journal of Transplantation. Powerful forces in the medical establishment are laying the foundations for a dramatic change in how we approach death and organ donation. Hippocrates is joining the ranks of the armless relics of antiquity. Paul Ramsey’s assessment in 1970 was prescient. We should gird ourselves for the coming wave of legalized assisted death and an organ procurement agenda.

Allen H. Roberts II, M.D., is professor of clinical medicine and chair of the ethics committee at Georgetown University Medical Center.