Vatican denies it’s trying to redefine death

September 4, 2008

L’Osservatore Romano with death article (right column), 3 Sept 2008 The Vatican has caused a stir by appearing to want to redefine death and then denying any such thing. If where there’s smoke, there’s fire, we haven’t heard the end of this yet.

It all started with a front-page article in the Vatican daily L’Osservatore Romano challenging the widely-accepted concept that brain death — the irreversible end of all brain activity — is the right standard for determining that someone has died. The article argued that doctors developed that standard 40 years ago to enable them to harvest organs for transplantation. The article by Lucetta Scaraffia, an Italian history professor and bioethicist, argued:

“The scientific justification of (the brain death standard) rests on a peculiar definition of the nervous system that is now being questioned by new research, which casts doubt on the fact that brain death leads to the disintegration of the body … The idea that the human person ceases to exist when the brain no longer functions, while the body is kept alive thanks to artificial respiration, implies an identification of the person with brain activity alone. This contradicts the concept of the person according to Catholic doctrine and thus contradicts the directives of the Church in the case of patients in a persistent coma.”

German nurse prepares brain-dead woman to donate liver and kidneys for transplant, 20 May 2008/Fabrizio BenschThe Vatican accepts organ transplantation and the brain death standard, which is widely used in Catholic hospitals. Declaring the brain death criterion un-Catholic would mean those hospitals would have to revert to the cardiac death standard alone. But that leaves a much smaller window for removing viable organs and would make one kind of transplantation — heart transplants — all but impossible. As it is, there is already such a shortage of organs for transplantation that scandalous black markets for them exist and some experts want to see organs sold like commodities on an open market.

The Vatican has not changed its view on brain death despite holding two scientific conferences (in 2005 and 2006) to discuss it, but there are dissenters among Catholic bioethicists like Scaraffia who want to keep the debate going. She used the 40th anniversary of the pioneering Harvard Report that advocated the brain death standard to call for a reassessment.

Rev. Federico Lombardi, the Vatican’s chief spokesman, got plenty of calls asking whether this was a change in the Church’s position. “This is not a Vatican document,” he responded. “It is an article by a historian that takes some considerations into account but it is not part of Church teaching.”

German doctor holds up kidney harvested from brain-dead patient, 12 january 2008/Fabrizio BenschEnd-of-life issues are some of the most difficult challengesin ethics and some bioethicists say people should choose their definition of death in advance to ensure they don’t leave the moral quandary to others.

The influential New England Journal of Medicine reopened this long-standing debate last month with an article questioning whether some patients declared brain dead were in fact really dead. Patients with massive brain damage can be declared brain dead even though their vital bodily functions continue to work, wrote Robert Truog of Harvard Medical School and Franklin Miller of the National Institutes of Health. “The arguments about why these patients should be considered dead have never been fully convincing,” they wrote.

Another criterion, the end of a heart’s beating, seems questionable when doctors can declare cardiac death and the transplant and restart the heart in another patient, they said. These cases suggested, they argued, that “the medical profession has been gerrymandering the definition of death to carefully conform with conditions that are most favourable to transplantation”.

Another article reported that doctors in Denver had taken hearts from three brain-damaged infants within 75 to 180 seconds after their cardiac deaths and then successfully implanted and restarted them in other babies.

In the same series, bioethicist Robert Veatch of Georgetown University’s Kennedy Institute of Ethics wrote that declaring cardiac death and then transplanting the same heart amounted to “ending a life by organ removal”.

Do you think the ethical issues that Scaraffia brings up justify a challenge to the brain death criterion? Or should the priority be on making sure doctors have as many organs for transplant as possible?

UPDATE:  Sandro Magister has just put out a very thorough analysis of this issue on his blog www.chiesa. For the English-language version, click here.

14 comments

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It’s such a touchy subject because there is still so much we don’t understand about the human psyche during death. With the Vatican getting into the mix it takes a touchy subject and turns it into hazardous material. There will always be conflict here.

Posted by Unfurth | Report as abusive

This ethical issue cannot be ascribed an either or status, more research must be permitted and reviewed.

Posted by Deborah Williams | Report as abusive

I think death should be defined as the moment at which there is no hope of recovery. Usually brain death coincides with this, but I don’t know if it is always so. Certainly cardiac arrest isn’t irreversible. I would think that the point of no return would be detected differently, depending on what kills the patient. In any case it’s not really an ethical question; it’s kind of obvious. We have to avoid removing organs from someone who otherwise had a chance to recover, so we need stats showing the correlation between certain indices (like EEG) and subsequent death or recovery.

Posted by David Bradley | Report as abusive

People of Earth need to stop the Vatican… It’s bad enough they are the richest country that ever existed, and they have their own government and army, but we’re in the 21st Century, the Information Age decides what is and what isn’t, not the fact manipulating false prophets at the Vatican. Death is death, there is nothing to define!

Posted by Will | Report as abusive

Several issues bearing on the ethics of defining death are not discussed in the article. Perhaps they were excised for brevity. First, the heart is not an isolated organ, it is strongly affected by the rest of the body it resides in. The heart that is “removed, transplanted to another patient, and restarted” may very well work fine in its new body, yet had it been left in the original (dying) body, it may well have been impossible to restart it.

Further, doctors have strict standards for whether performing a procedure benefits the patient overall. If not it is malpractice. Yet the layman here may wish that cardiac restart via electric shock, drugs, etc be attempted as long as possible in the hope that the donor’s body might have the maximum chance to live. From a doctor’s perspective, though, going beyond the point of a reasonable expectation of survival is tantamount to tormenting a dead body solely to wrench a few more heartbeats out artificially. Thus there is a medical point at which a heart may be theoretically forced to produce additional beats in the body of the donor, yet to do so is not in that person’s interest.
The important question is whether the judgement of the doctor that this point has been reached is skewed at all by his desire to obtain a transplant organ.

Posted by Bill L | Report as abusive

Thanks, Bill L, for a well thought out and intelligent comment.

Posted by chris (usa) | Report as abusive

This is a bit of a beat-up headline. The definition of ‘death’ is a difficult philosophical and technical issue in this age of transplantation and intensive care, but the vatican continues to hold the same definition as most of the medical community. The fact that one historian who happens to be catholic disagrees doesn’t change this, any more than a Democrat mayor pleading guilty to lying under oath makes Democrat central committees dishonest!

As a doctor working in trauma, I appreciate the thoughtfulness that philosophers, theologians, and my profession have put into this issue, especially when it comes to families trying to reason out what is the best course of action for their brain-dead relative. Certainly the catholic position seems based on systematic philosophy and with reference to medical science. Knee-jerk anti-catholic responses such as Will’s certainly add nothing to the debate.

Posted by David | Report as abusive

at first the vatican and his long and deadly history of interference into science (creation, evolution, galileo, contraception) and his crazed perceptions as to when and where life or the world start and end should be put to rest. second the ethics of doctors have to be questioned and be compared to their greed and strive for fame. authorities spare every single dollar they can to educate and feed their people (we don’t have money), but waste millions of dollars on weapons and high tec clinics to first kill as many as possible and then keep dead bodies artificially animated. that is inhumane.

Posted by Stephan Cyriacus | Report as abusive

The problem is not one of defining death. Instead, the problem is one of applying a definition of death as a practical matter. These line-drawing issues will probably not go away as long as organs are harvested for transplantation, because the practice necessarily involves harvesting the organs as close to the time of death as possible. Otherwise, the definitional questions might not attract much interest.

Posted by Bob | Report as abusive

These sorts of debate never seem to get truly “settled” until the point is rendered moot. In a few years, when 3-dimensional printing technology is making new hearts for cardiac patients, or scientists have found a way to convince a skin cell to grow a kidney, then someone will declare for the record what qualifies as death. And the real decider will probably not be the church, or research scientists, or medical doctors. It will be your friendly neighborhood insurance company defining what constitutes death.

Death will be the point where your medical insurance stops functioning.

Posted by jennifer c | Report as abusive

To Bill L and David — thank you for your thoughtful responses. I think you’ll understand that our coverage of this issue is necessarily written for a general audience and so there are bound to be some aspects of the problem left out for space reasons. If Reuters published a piece with the philosophical depth and scientific complexity of the materials I cited (especially the NEJM articles), most general readers would stop reading after the first few paragraphs. The headline also had to start from a general assumption — i.e. that we all know what death is — to lead into an article explaining how much more complicated the issue is.

Lucetta Scaraffia’s article would rank as just another article by a Catholic bioethicist if it hadn’t been published so prominently on the front page of the Vatican’s newspaper. For journalists covering the Vatican, L’Osservatore Romano is a weathervane of discussions and possible changes within the Church. It is not the mouthpiece of the Church, but we naturally we sit up and pay attention when it highlights something like this.

Another factor behind this is explained in the link in paragraph 5 under “dissenters among Catholic ethicists” — there is a minority that wants to drop the brain dead criterion and it has defied normal Vatican custom and published its minority view from a conference whose proceedings the Vatican chose not to publish. This book seems to have appeared last year in English and earlier this year in Italian, the latter giving Scaraffia a peg for her article.

For a fuller analysis of this issue than we would do, take a look at the item that the Italian Vatican watcher Sandro Magister posted today on his blog. The English-language version is at http://chiesa.espresso.repubblica.it/art icolo/206476?eng=y

Posted by Tom Heneghan | Report as abusive

If the brain dead person can maintain cardiac and respiratory activity without external support, then that person must be considered alive. If that person, however, requires artificial ventilation or other artificial support past a resonably short time to repeatedly verify brain death, then the artificial support must be removed and God’s will be done.

Posted by J PETTIT | Report as abusive

We USED to know when people were ‘dead’! There was a standard we went by for thousands of years. The criteria was…”The Breath of Life”. Think about it. Having sat with several folks, family and friends, in their last moments alive, what we see is the ‘breath of life’ leaves them. They cease to breath.
Their hearts can be doing all kinds of things, even halting at times; and their brain-waves who knows…they aren’t talking in their struggle. BUT, they are breathing oxygen, are warm, and sometimes open their eyes to acknowledge our presence.
Near the end of that, they transition into Braxton-Hix breathing, heavy and deep, as tho in labor. Then comes the moment one takes the last breath, and exhales.
There is a spirit in man the Scripture says, and when one dies, it says that spirit goes back to God/El who gave it. So from that all, it seems sensical to me, that since when a baby is born, he takes that first breath, he/she pinks up and cries, so as to breath deeply; so at the end that same breath of life leaves them.
That’s when they used to be considered dead. When was it that man suddenly, in our day and age got smarter than God/El?
In some European countries, the father still breaths into the baby ‘the breath of life’,for that first breath. In America we are so sophisticated, we hang them upside down by their heals and beat their butt. I’ve thought about that. Who would want to be born into a world where the first thing you get is a drop of temp of nearly 30 degrees, and the first thing that happens is someone hangs you upside down and gives you a whack!
I’ve wondered if perhaps the sudden extreme drop in temperature was the reason that causes many babies to come out wailing on their own. I certainly would howl under that circumstance.
In olden days, the father or whoever breathed into them a breath of life, then they wrapped/swaddled the little one for warm and cozy, and handed them to momma to put to breast to be comforted, which causes things to contract so moms don’t hemorrage. Now days they don’t put baby to breast, they give a Vit.K shot to prevent hemorraging. Babies get probed and jabbed, laying bare, for a time before finally getting swaddled and put into mom’s arms so she can comfort baby and examine the fruit of her womb, the child of her beloved husband.
I really like the old way of birth, and the old way of dying was better too, at home with those you love around you. And they ALL knew it was when grandma or grandpa stopped breathing,that they were gone, because they didn’t pay any attention to what the heart or brainwaves or toenails were doing.

To Mathilda — In many ways the image you evoke of a more holistic way of dying, naturally and at home, without having to breathe your last breath while hooked up to multiple machines, is very heartening. Certainly there are now far too many cases today where defining the point of death, or even failing to allow death to happen when it naturally would occur because of the use (and misuse) of medical technologies.

However, in those past times, identifying the point of death was still a very problematic issue. Before the early 20th century, the great fear was of being buried prematurely, ie. while still alive. People in their wills often specified that a device such as a bell with a pullcord be put next to the grave, with the pullcord extending into their coffin, to call for help if they found themselves waking up six feet under. Others would specify that their veins be opened before burial. Of course the widespread modern use of embalming now achieves much the same thing as opening veins.

These fears were apparently well founded, as there is evidence that when graveyards were occasionally dug up and moved, the workers found scratch marks on the inside lids of coffins, made by the fingernails of the not quite deceased occupant. In fact I believe that the original purpose of a ‘wake’ was to monitor the supposedly deceased, lying in her open coffin, 24 hours a day for a few days to make sure she was truly dead and did not wake, hence the name.

All this strongly indicates that identifying the point of death from the ‘last breath’ was, if anything, even more problematic than the current medical ethics issues the Vatican is trying to address.

Posted by Bill L | Report as abusive

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