NEW YORK—Sacred Scripture says that man is appointed to live once and then die. The number of years allotted, however, has tended to increase in recent times with better nutrition, hygiene, and medical technologies. Those same medical technologies also have influenced the way that death is determined and raised serious moral question about the appropriateness of some organ transplants.
The moral problems are not always raised by the promoters of what Pope John Paul II has called “the culture of death,” who seek to reshape society's view of life and death through abortion, “morning-after” pills, euthanasia, and physician-assisted suicide. In the case of “brain death,” faithful Catholic physicians and moral theologians have politely engaged one another in a debate that is not given to easy resolution and may continue for some time.
Recent articles in the journal of the Catholic Medical Association (CMA), The Linacre Quarterly, include a neurologist's explanation of why he has radically changed his view to the point where he now writes “brain death is not true death,” and a medical ethicist who states in the May issue, “There is little doubt that acceptance of the practice of diagnosing death by the death of the whole brain criterion is collapsing. Both the ethical and medical literature contain articles indicating an overwhelming flaw.”
‘Brain death’ is a non-medical term that was invented to allow the harvesting of vital organs from patients who may be dying but not yet dead. Taking organs in such cases actually kills the patient.
At the CMA's annual convention in New York City earlier this month, amid a rousing consensus on the obligation of the Catholic doctor to be a light in a darkening ethical world of medicine, a hearty debate ensued over “brain death.”
Dr. Paul Byrne, the outgoing CMApresident, said in a lecture that “brain death” is a non-medical term that was invented to allow the harvesting of vital organs from patients who may be dying but not yet dead. Taking organs in such cases actually kills the patient, he stated.
Opponents of his view admitted that a person is more than the mere functioning of his brain, and that all precautions must be made to guard against death-by-transplant. Still, they held that death of the brain, marked by cessation of discernible brain functions, is a reliable guide in determining death.
“Physicians should not declare death till sufficient destruction of the body has taken place naturally, so that there is certainty that what they have before them is a corpse,” Byrne, a neonatology doctor from Toledo, Ohio, told the Register.
The Church defines death simply as the separation of the soul from the body. But as Msgr. William Smith, one of the nation's foremost moral theologians, explains, “We don't have a snapshot of when this happens.” Methods for determining the time of death beyond a reasonable doubt must be employed, and the current debate within Catholic circles is really about what a particular doctor or scholar considers “reasonable,” he said.
Echoing the opinion of other experts, Msgr. Smith called Byrne's view an extreme one which calls for an unnecessarily high standard for determining death.
“He wants a criterion for brain death that is really brain destruction,” Msgr. Smith said in a Register interview.
In 1985 and again four years later, a specially appointed panel for the Pontifical Academy of Sciences endorsed the concept of “whole-brain death” as true death. In the latter meeting, the group of medical experts was addressed by John Paul II, who expressed the Church's deep interest in the issue as part of its concern for the unique dignity of human life, made in the image of God.
The Pontifical Academy stated that “a person is dead when he has irreversibly lost all ability to integrate and coordinate the physical and mental functions of the body.” The moment of death comes when “the spontaneous functions of the heart and breathing have definitively ceased, or (with) the irreversible arrest of all brain activity.” The report noted that brain death inevitably leads to cardiopulmonary arrest.
The Pontifical Academy's finding is not an infallible teaching or even an exercise of the ordinary magisterium. It is an expert opinion offered to the Pope and the Church at large. The fact that the Pope has not refuted the finding, though, indicates that he does not find it contradictory to Catholic faith or morals. Many Catholic medical facilities and doctors operate on the understanding that a patient who is declared brain dead may be removed from life-support systems and have vital organs taken with proper permissions.
Two years ago, however, John Cardinal O'Connor took a controversial step by accepting a 5-month-old brain-dead girl into St. Vincent's Hospital in New York City. A state Supreme Court judge had ruled that the baby, Mariah Scoon, could be removed from life-support at another hospital against the wishes of her parents. In accepting the baby, the cardinal said he was acting out of compassion for the parents and to emphasize the sanctity of human life. Although he said he did not dispute the medical finding of brain death, he stated that the baby's life would be “prolonged until God decides” to take it. The baby died days later.
The Charter for Health Care Workers issued in 1995 by the Pontifical Council for Pastoral Assistance to Health Care Workers, said of the Academy of Sciences report: “Moral theology, in fact, cannot but acknowledge the biomedical determination as the decisive criterion” for determining the point of death, but adds that the Church demands “of health care workers the most accurate use of the various clinical and instrumental methods for a certain diagnosis of death.”
New medical facts are becoming available on the ability of brain dead patients to continue living. The Charter quotes a 1957 address to doctors by Pope Pius XII that it lies within the competency of medical science to determine the precise moment of death using rational criteria.
Medical science, however, is showing increasing uncertainty in the matter, at least among Catholic experts. Not only are new medical facts becoming available on the ability of brain dead patients to continue living, medical experts are interpreting the existing medical data in different ways.
Like some of the problems addressed by St. Thomas Aquinas in his day, the issues raised by brain death are scientific, philosophical, and theological. The challenge is to integrate the disciplines to come to rational conclusions.
Msgr. Smith, professor of moral theology at St. Joseph's Seminary in New York, said, “If someone gives me irrefutable scientific evidence, I know what principles to apply.”
One of the more deep and eloquent treatments of the topic was given by Dr. Alan Shewmon, professor of pediatric neurology at UCLA Medical School, in the February 1997 issue of The Linacre Quarterly. A Jewish convert to Catholicism, his article traces his 20-year journey from the secular view of brain death to questioning the 1989 finding of the Pontifical Academy of Sciences, of which he was a prominent member.
The prevailing view of the human person gives primacy to consciousness and the ability to communicate an inner state — those who cannot express this inner state are thought to be non-persons, even when they are recognized to be human and in some way alive biologically, he writes. The mind, he adds, is seen by most medical experts as the organ integrating the mental and physical powers (much as the soul is recognized by theologians to be the “form” of the body). Thus, when the brain is unable to function, the person is thought to be unable to live. According to his revised view, Shewmon writes, “death occurs when failure of multiple vital systems and bodily processes (including the brain) progresses beyond a systems-dynamical point of no return. Although some ‘brain dead’ patients may be truly dead, it is not because their brains are dead but rather because” of critical multi-system damage. Brain dead patients whose other organ systems are intact, “are not yet dead but are rather fatally injured and in a deep coma.”
This view of death of course rules out taking organs from the latter category of patients. Yet, Shewmon writes, organs may be taken from “non-heartbeating donors” whose lack of pulse has continued long enough to ensure that heartbeat and circulation will not resume spontaneously.
Assessing the widespread support for brain death diagnoses, he continues, “Historically, the reasons for introducing the ‘brain death’ concept in the late 1960s were pragmatic and twofold: legitimizing the discontinuation of ventilators and the transplantation of unpaired vital organs.”
Dr. Walt Weaver, a cardiologist in Lincoln, Neb., who has performed a number of heart transplants, thought he was doing an unmitigated good until he evaluated a young motorcycle crash victim who was declared brain dead. Though the teen-ager was on a ventilator, he had warm, healthy looking skin, self-controlled temperature, and a sustained blood pressure, and he was producing urine naturally.
“How could I say that this young man was dead?” said Weaver. He stopped doing transplants shortly thereafter.
Stressing the findings of the Pontifical Academy, Msgr. Smith said that it is theologically possible to “ventilate a corpse” after death has with certainty taken place. Once death has been carefully determined, he said, the dignity of human life is not necessarily promoted by performing such a ventilation, he said.
Brian Caulfield writes from New York.