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Most of the audience were students and physicians. But this man looked more like a patient. The panel discussion, part of a third year round, Brain Death and Organ Transplantation, was open to the public.
I’d been arguing, on the basis of well known data,1–4 that “brain death” is not death. So, taking a heart from a “brain dead” (BD) patient is killing. But I would not totally oppose killing patients for their organs, provided that there is informed consent, and with further limitations. Truog’s proposal to take organs from persistent vegetative state (PVS) patients2 is too extreme. Patients in a persistent vegetative state sometimes return to various levels of consciousness.5,6 So killing them for their organs is a dangerous precedent. But although there is widespread belief in inevitable asystole “within a few days”,7 patients can continue in the BD state for six or more months.4 But BD patients don’t return to consciousness. So brain death seems a legitimate minimal cut off point. I also argued for a policy similar to New Jersey and Japan, which allows a donor “to choose between ‘brain death’ and ‘traditional death’”,8 and would go further and allow different definitions of brain death. Capron opposes such liberality.9 But if they are my organs, why shouldn’t I be free to choose when—if at all—to donate them? This kind of policy can encourage more donations. Those who agree with brain death may continue to consent as usual. Others might agree to organ and tissue donation after “cardiologic death”, making more kidneys, corneas, and skin available.
In the discussion session, the man asked how he might donate his organs. He received more enthusiasm than did I. One does not win popularity contests by criticising brain death in a medical school round on transplantation. But if “surveys show that one third of physicians and nurses do not believe brain dead patients are actually dead”,10 the position that we are killing patients for their organs, should be heard. The rabbi on the panel, one of the many orthodox who accept brain death, opposed me as strongly as did the surgeon.
After the session, the man approached me: “That doctor does not want to help me. I want them to anaesthetise me and take my organs. My life has been a waste. I want to help people.”
He admitted being under psychiatric care. He reluctantly gave me his name, and the name of his psychiatrist. My telephone call alarmed the psychiatrist. The man had never been suicidal before.
Did my statement, made in a prestigious forum, that we are killing people for their organs, influence this man to decide to volunteer for donation? Of course, he is mentally ill. But if my view, and that of Truog,2 were to become well known, might not this encourage even the sane to make similar decisions, perhaps for money for their families?
The guiltridden American prisoner, who asked to be killed for his organs, was declared “sane” in court. He was refused on grounds of an obligation to preserve life.11 If suicide is sometimes justifiable, then it might also be justifiable to kill oneself by removing one’s organs for donation, if it were possible. But if assistance is needed, an “autonomous” act does not affect only oneself. What does killing do to the killer? What psychological effect would killing conscious, ambulatory patients have on physicians? Killing potentially conscious PVS patients would be traumatic enough.
I am not ready to say that brain death is really death, when I don’t believe it. But am I justified in broadcasting my opinion and risking encouraging more volunteers?
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