Is death really irreversible?
Brain death was considered to be firmly defined. New discoveries are forcing medical professionals to ask the question of when a person is really dead. This could change the way organ donation is handled.
Legally, the matter is clear: "A person is dead when the functions of their brain, including the brain stem, have irreversibly failed", states Article 9 of the Swiss Transplantation Act. Seen in this way, death and brain death are the same. Transplant medicine is based on this principle - that a person is actually dead if his organs are removed for an organ donation.
But whether the equation brain death = death is actually correct has recently been the subject of controversial debate. "New insights require a new approach to these questions," says the psychiatrist Sabine Müller from the Charité in Berlin. Numerous studies have shown longer survival and the maintenance of bodily functions in brain-dead patients.
Franz Immer prefers to avoid such studies. The director of the national foundation for organ donation and transplantation (Swisstransplant) is concerned with other issues. He recently launched a debate on the more benefit-oriented allocation of donor organs or put the so-called contradiction solution up for discussion (see box on page 58). Immer does not want to bring up brain death. "We held this discussion in Switzerland 10 years ago and put it aside," he says succinctly.
Not everyone sees it that way. "The renewed examination of brain death is important, especially when society receives new proposals for organ donation," says Zurich ethicist Ruth Baumann-Hölzle. The "Frankfurter Allgemeine Zeitung" considers the debate to be "long overdue," because: "What we know today about so-called brain death is being put to the test by transplant medicine," the newspaper wrote. In the USA, where the concept of brain death was developed in the late 1960s, the controversy has been running for a long time. In December 2008 the President's Commission on Bioethics came to the conclusion that the biological reasons for the definition of brain death had proven to be erroneous.
Until recently, the brain was seen as an integrator of the various body functions. And it was assumed that the body immediately ceases to function as a whole after the brain functions fail. This assumption was wrong, as we know today. The process of physical "disintegration" takes much longer.
For example, brain dead maintain the state of equilibrium of the organism (homeostasis). As Sabine Müller describes, the brain dead regulate their body temperature independently, they fight infections (including fever) and injuries, react to pain stimuli with a rise in blood pressure or produce excrement. Brain-dead children grow and continue their sexual development. Brain-dead pregnant women can maintain the pregnancy for months and deliver healthy children - up to 2003, 10 such births were documented. In all of these cases, the deceased's blood circulation was maintained by the doctors in the intensive care unit with artificial ventilation and other measures.
The examples show that when the cortex and brainstem are dead, the body is far from exhausted - even if the ventilator is switched off. That has to do with the complexity of the human nervous system, says Peter Suter, professor emeritus for intensive care medicine in Geneva. "Many nervous functions are not controlled by the brain, but run through the spinal cord, for example." That is why such vegetative reactions or reflexes occur.
For Suter, who also presides over the Swiss Academy of Medical Sciences (SAMS), one thing is clear: humans are no longer what they were as soon as the cerebral cortex is dead. The SAMS guidelines on the “Determination of Death”, which are relevant for organ transplants, are also based on this concept. The “President's Commission” redefined brain death and stated that the brain dead “lack integration into the environment”; life is extinguished when, in addition to all brain activity, breathing fails. Peter Suter does not consider such a redefinition to be inappropriate, but it is unnecessary.
Anesthesia for the dead
Ruth Baumann-Hölzle says she has never understood why the failure of brain functions and death should be one. "Nevertheless," she emphasizes, "from my point of view, brain death is an irreversible point in time, a turning point that will inevitably be followed by death." Ultimately, dying is a secret and a process. "We can approach this scientifically, we will never understand this event in its depth."
A few years ago, British anesthetists called for general anesthesia for brain-dead organ donors when removing organs in order to avoid possible pain. One of them told the BBC: “You put on the scalpel and your pulse and blood pressure go up. If no medication is given, the patient begins to move and the procedure becomes impossible. " He advocates organ transplants, but would only carry a donor card with him if he knew he would be anesthetized before organ removal.
Peter Suter understands this attitude. In Switzerland, organ donors are consistently anesthetized when removing organs - out of respect because they are “still human”, as Suter emphasizes. A dead person, however. The SAMS President also says this with regard to the other group of possible organ donors: patients who primarily die of heart failure, the so-called Non-Heart-Beating Donors (NHBD). While in the brain dead the brain dies first and then the organism, it is the other way around with the NHBD: First the heart stops beating - be it due to acute heart failure or after treatment has been discontinued in the intensive care unit - then brain death ensues.
The group of the NHBD is in the minority compared to the brain-dead donors, but their share is growing steadily worldwide. Part of the reason for this is the fact that 80 to 90 percent of deaths in intensive care units occur because therapy was discontinued in the corresponding patients. Some of them are potential donors. In this case, however, only the kidneys can usually be used, possibly also the lungs. For the heart, however, the 20-minute waiting time after cardiac arrest, which the SAMS guidelines for organ removal prescribe, are too long.
Such organ removal was practiced in Geneva and Zurich until 2007, but stopped after the Transplantation Act came into force. The reason: a potential NHBD is still alive when his relatives are asked about the organ donation. So far, this has apparently been in contradiction to the law. Nevertheless, the NHBD programs are now to be reintroduced. A lawyer from the Federal Office of Public Health (BAG) came to the conclusion that organ removal after cardiac death complies with the law.
"A sacrifice - and a gift"
But what gives the advocates of organ donation hope for higher donor numbers causes others to frown. For example with Bruno Regli, deputy head physician of intensive care medicine at Inselspital Bern: The process is more difficult to lead than with regard to brain death, he says. "If I discontinue therapy in a patient with a hopeless prognosis and wait for cardiac death, the discontinuation criteria are not as clearly defined today as they are with regard to brain death." In addition, especially in centers where transplants are carried out, it is more problematic to rule out any possible bias on the part of the intensive care doctor as a decision maker, says Bruno Regli. He himself is not so rarely involved in the treatment of future recipients.
For Ruth Baumann-Hölzle it is clear: The public has to deal with the new knowledge about brain death as well as with organ donation after cardiac death. The ethicist demands that brain death and cardiac death must be listed separately on the donor card. “Organ donation cannot be taken for granted,” says Baumann-Hölzle. "It's always a sacrifice - and a gift."
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