Brain Death and Organ Donation
in Children and Adults

Emily Beck



Outline

Thesis: Decisions regarding organ donation and when an unconscious person has died or experienced brain death are very difficult decisions for the family to make, even with the help of medical professionals. Organ donation started in 1869 and since then the procedure has improved but doctors with unethical practices still, and always will, exist. After all of the improvements in adult organ donation, questions still remain about organ donation and anencephalic infants. Should these infants be treated as human beings, should they be allowed to donate their organs? What happens to any infant whose mother dies before delivery of the child?



A) Introduction
B) Definitions
1) Death
2) Brain death
C) Adult Organ Donation
1) Process
2) History
3) Unethical practices
4) Xenograft
5) Legislation
D) Anencephaly
1) Legislation
2) Organ donation
3) Human Beings
E) Expectant Mothers
F)Conclusion



Introduction


Does one try to save a premature baby who has little chance of survival? When do doctors or family members decide to "pull the plug" on a loved one? When is organ donation the correct choice? Is this patient the one on which God will choose to perform a miracle? What about a postmortem delivery? Is it realistic to be able to have a child postmortem?
These questions are difficult for any of us to answer - even more so if we are dealing with a situation in which we may have to answer one or more of these questions. Yet, for some of us, these questions are all too real. If someone is considered to be in a vegetative state and the doctor determines that they are not coming back, when do family members decide to let go? When do family members give up hope?
These questions can only be answered once a person is faced with a situation where he or she needs to determine another's fate. All of the answers to the questions are personal answers and no one should judge another person for making a choice in a difficult situation. Decisions regarding organ donation and when an unconscious person has died or experienced brain death are very difficult decisions for the family to make, even with the help of medical professionals.
Organ donation started in 1869 and since then the procedure has improved but doctors with unethical practices still, and always will, exist. After all of the improvements in adult organ donation, questions still remain about organ donation and anencephalic infants. Should these infants be treated as human beings, should they be allowed to donate their organs? What happens to any infant whose mother dies before delivery of the child?

Definitions

Everyone has different definitions for death. To some death has occurred when the emotional aspect of the patient is no longer functioning. To others, socializing is very important to life. And for others, communication is the key. The definition of death is "the act or fact of dying, permanent ending of all life in a person, animal, or plant" according to Webster's Dictionary. Mason defines death in terms of "irreversible failure of the cardiopulmonary system or consequently as a permanent state of tissue anoxia." (43). Another definition that should be addressed is the definition of brain death. According to Stedman's Medical Dictionary, brain death is "in the presence of cardiac activity, the permanent loss of cerebral function, manifested clinically by absence of purposive responses to external stimuli, absence of cephalic reflexes, apnea, and an isoelectric electroencephalogram for at least 30 minutes in the absence of hypothermia and poisoning by central nervous system depressants." (142). If the heart is functioning, but the cerebrum is not functioning, the patient can be declared to be brain dead. To determine if the cerebrum is functioning, doctors would analyze the responses of the patient to external stimuli, run an electroencephalogram, check for cephalic reflexes, and check respiration of the patient. Lamb states that the absence of spontaneous respiration and circulation is not a sign of death, which is determined only when the physician is satisfied that the brain has ceased to function (31). Testing for respiration and circulation are simply tests to determine brain activity.
When looking at issues concerning anencephaly, organ donation, and the legislation protecting the people of the United States one can make reference to Mason's definition of death and the aforementioned definition of brain death. Another definition to keep in mind is the Harvard Committee Criteria for determining when death has occurred. The criteria that the Harvard Committee suggests using states that if the patient is
1) "unreceptivity and unresponsivity" to "externally applied stimuli and inner need"
2) absence of spontaneous muscular movements or spontaneous respiration
3) no elicitable reflexes
then the patient can be considered dead. The Harvard Committee also states that a flat electroencephalogram has 'great conformity value' in helping to determine if a patient has experienced cerebral death or death (Humber 558).

Adult Organ Donation:Process

When considering organ donation, the doctors want to be absolutely positive the patient is no longer living, but the body can not stop functioning if the doctors want to harvest organs. If organs do not receive adequate blood flow with oxygen rich blood, the organs will rapidly deteriorate, thus making the organs unfit for donation (Koukl). Since so many people are awaiting organs, doctors do everything possible, including life support, to keep oxygen rich blood circulating through the patient's body until the family has made a decision.
The organ donation process goes something like this:the patient is admitted to the hospital with life threatening injuries. Everything possible is done to try to save the patient. The patient needs to be pronounced dead or brain dead by the attending physician and another physician. Neither of these physicians can be on a transplant team that will be procuring the organ(s) for the recipient nor the recipient's doctor. At this point the family can decide to donate the organs of the patient, if they so desire. If organ donation is agreed upon by the family, written consent is given and the transplant team is brought to the now deceased patient's hospital. After procuring the organs, the transplant team flies to the recipient's hospital to place the "new" organ(s), which are being cooled and preserved, into the recipient (Henderson 9). The transplant team has little time in which to work once the organs have been procured. For a heart or lung transplant the maximum time a transplant team is given is four hours before irreversible damage is done. Transplant teams have twenty-four hours to transplant the liver and pancreas. Skin can be transplanted up to two years later and heart valves can be preserved for ten years (Henderson 12).

Adult Organ Donation:History

Organ donation sounds like a recent advancement in medical technology. But transplants have been around for about 130 years. The first transplant was done in 1869 and it was a skin transplant. It was not until 1906 that another type of transplant was successful. Doctor Edward Zirm transplanted a cornea 40 years after the first successful skin transplant. Finding organs to transplant has become increasingly easier since 1949 when the U.S. Navy Tissue Bank was established (Henderson 14). Since 1869, doctors and researchers have been discovering better techniques to transplant and preserve organs, also more reliable equipment is constantly being produced.

Adult Organ Donation:Unethical Practices


Organ donation sounds easy and it is, but deciding when to procure organs from an individual who has a head injury and diminished cerebral activity is difficult. The brain stem may still be functioning without mechanical help, so respiration and circulation are occurring spontaneously. Physicians and neurologists depend on the Harvard Committee Criteria and a flat electroencephalogram to determine death (Humber 558). German researchers now have reason to believe that the brain stem has some primitive forms of psychic activity (Lamb 67). This finding can change a person's or family's view on what to do if the brain stem is the only known functioning area of the brain. If primitive forms of psychic activity are occurring, then how much can the patient feel, reason, or understand what is happening around them. The patient obviously does not have the cognitive resources that he or she had access to before the accident, but nonetheless, how primitive is the psychic ability? As of now there is no reason to believe that a person with no detectable cerebral activity will be able to regenerate cerebral activity later. But researchers still have a lot of unanswered questions, such as the question can cerebral activity occur at a level that can not be detected by all of the modern technology available today? How much of the primitive psychic activity takes place in the brain stem?
Two physicians not involved in the transplant team and not involved with the recipient need to pronounce the patient's death. This is done to prevent a doctor from unethical practices and irreversible actions. In a busy, crowded hospital, a doctor could very easily pronounce a patient brain dead when the patient is simply unconscious, or more likely, in a coma. By pronouncing this first patient brain dead, the doctor could free up a bed for another patient and hopefully get the "brain dead" patient's family to agree to organ donation. According to Ackerman, if the brain stem is functioning, then the patient is legally alive and this type of situation would be highly unethical (92). Legislation does state that 'death is to be pronounced before artificial means of supporting respiratory and circulatory functions are terminated and before any vital organ is removed for the purposes of transplantation.' (Lamb 72). In a big, crowded hospital the doctor may be betting on other medical staff being too busy to really notice the 'brain dead' patient is not really dead. Since legislation does state that the body needs to have respiratory and circulatory functions maintained until death is pronounced. The doctor may be able to slip a "brain dead" patient through without much trouble. To be able to harvest organs, respiratory and circulatory functions need to continue until the operation when the organs are removed for transplantation. This situation sounds highly unlikely, but some people are desperate. Performing a transplant would increase the doctor's salary for the week. So some of this legislation stops doctors from declaring early death and also stops doctors from padding their incomes.

Adult Organ Donation:Xenograft


One type of transplant that has not been mentioned yet, but probably should be mentioned is a xenograft or the transplant of animal tissues to humans. A xenograft has one of two purposes. One, the animal organ can be used as a "bridge" until a human organ is found. This is just a way to prolong someone's life a little longer in the hope that a human organ will be found. The second use for a xenograft is as a permanent transplant (Pothier). According to Gorman, a xenograft can be a fairly dangerous transplant because researchers are not sure what type of viruses or diseases primates, or other animals that could be used in transplants, might have that can not be detected. The most commonly used animals are the primates, pigs, cows and deer. Researchers feel more comfortable using the primates for transplants because of the close relationship between the primates and humans. But when it comes to protecting the human population from disease, researchers feel better using pigs, cows, or deer because the diseases will need to change form quite drastically to infect or harm the human population (Gorman).

Adult Organ Donation:Legislation


For adults, the legislation that involves two physicians declaring a patient dead seems to work well, although abuses can still take place. But organ donation for children is quite different. A newborn infant with anencephaly can not be used for organ donation until the brain stem quits functioning. In case one is wondering "anencephaly is a congenital birth defect in which the infant is born without a forebrain and a cerebrum, but is able to survive for a short time with a brain stem that permits breathing, sucking and other autonomic functions." (Koukl). This resembles the adult version of brain dead, yet the infant's organs can not be procured until the brain stem quits functioning. As mentioned earlier, the organs need to have a constant supply of oxygen rich blood in order to preserve the organs in the body. Without oxygen, rapid deterioration takes place, making the organs unfit for donation and transplantation. So an infant with anencephaly can not donate organs to other children desperately in need of organs. Adult organs are too big for children's bodies. So the children need to wait for another child to be fatally injured. This legislation regarding anencephaly is to protect the infant from parents desperate to save an older child. Legislation does not want parents having more children in order to donate organs to another child. If anencephalic children, who have no cognitive reasoning because they lack a cerebrum and forebrain, are considered alive with a brain stem, then why are adults considered dead with the same amount of activity?

Anencephaly:Legislation


The other side of this issue is that some people argue that anencephalic infants are not humans (Koukl). If this is how people feel, then why is there legislation to protect them? These people look at anencephalic infants as something other than human because anencephalic infants do not have a cerebrum or the capacity to have higher cognitive functions (Koukl). If a child or adult is severely mentally retarded, and has an I.Q. of one, what happens to them? Are they treated poorly because they do not have the capacity for higher cognitive functions? Koukl suggests that if anencephalic infants can be used to donate organs, then what is to stop us from using severely handicapped people as organ farms?

Anencephaly:Organ Donation and Human Beings


Yet, for the parents of an anencephalic infant, it would be nice to have the option of organ donation. Some parents may feel compelled to help another family, since their own child has a very slim chance of living for very long. In adults, doctors do not have to wait for the natural death of the brain stem to occur, then why in infants when the forebrain and cerebrum are missing, do doctors need to wait for natural death to occur? The parents should be given the option of allowing natural death to occur or allowing their child to become an organ donor. When children are born, if by the actions and behavior of the child, there is reason to believe that the child does not have a forebrain and cerebrum, a CAT scan should be preformed. If the CAT scan comes back showing evidence of a complete brain, then everything is OK, but if there is an absence of the forebrain and cerebrum, then a decision about what to do can be determined by the parents of the infant. Using a method such as this, no one can claim that the parents brought the child into this world only to harvest the child's organs. Anencephalic infants can not undergo some spontaneous reaction to develop a forebrain and cerebrum, therefore when no activity in those areas shows up on an electroencephalogram, the physician should be able to declare them OK for organ donation, if the family so desires. The same areas are working in the adult, who is lacking higher cerebral functions, and the anencephalic infant. The adult is considered dead and the infant is considered alive. Some legislative acts do not seem to make sense, although, in this case, legislators are trying to protect the children.

Expectant Mothers


What can be done to save an unborn child if the mother is being supported by life support and has no cerebral activity and no prospects of recovering? One option would be to try to save the unborn child no matter what the cost. The only drawback being that the mother would need to have a Caesarean section a few days after her death has occurred. An expectant mother in a vegetative state can keep an unborn child alive in her womb for up to 28 weeks (Lamb 105). Returning to the mother who gives birth postmortem, if the baby is born at 25 weeks then the baby has a 38% chance of living, at 26 weeks the chance of survival rises to 62%, and at 27 weeks the survival chance is 76% (Lamb 106). It is amazing what two more weeks in the uterus can do, and part of those weeks could be postmortem. With technology today, more moms that are fatally injured while expecting will be able to give birth to a live baby postmortem.

Conclusion


With all of the medical technology that is available today, determining when a person dies has not improved very drastically. The stethoscope is still one of the most important pieces of equipment in determining if a person has died. Respiration can be checked by watching the chest rise and fall, with a mirror, or by feeling the expelled air on your cheek.
A lot of advancements have been made in organ donation and transplantation since the first reported skin graft in 1869. Today's techniques can and will be improved upon, just like the earlier techniques have been improved. Organ donation is a widely accepted occurrence that benefits all of those involved. The legislation regarding when an infant can donate organs will change as more information is compiled regarding human physiology. The children need to be protected, yet saved. Postmortem mothers are delivering live babies. What is the next medical advancement in death, dying, and organ donation?

Works Cited


Ackerman, Terrence. A Casebook of Medical Ethics. New York:Oxford UP, 1989.

Gorman, Christine. "Are Animal Organs Safe for People." Time. 15 January 1996.

Henderson, Allen. Get With It-Teen Perspectives on Donation. The Indiana Heart Institute. 1994.

Humber, James M. Biomedical Ethics and the Law. 2nd Edition. New York: Plenum, 1979.

Koukl, Gregory. "Babies as Organ Farms". L.A. Times. 8 June 1995.

Lamb, David. Death, Brain Death and Ethics. Albany:New York UP, 1985.

Mason, JK. Human Life and Medical Practice. Great Britain:Edinburgh UP, 1988.

Neufeldt, Victoria. Webster's New World Dictionary. 3rd Edition. New York: Prentice Hall, 1991.

Pothier, Richard. "Animal Tests Saved My Life." Newsweek. 1 February 1993.

Stedman, Thomas Lathrop. Stedman's Medical Dictionary. 24 Edition. Baltimore:Williams and Wilkins, 1982.