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.”

The 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.”

End-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.

Before it slips from the news, take a look at a scandal in India that illustrates one of the biggest bioethical challenges we face in a globalised world. Last weekend, Nepal handed over to Indian authorities an Indian man arrested on suspicion of running a huge illegal kidney transplant racket. It seems this ring duped poor Indians into selling kidneys that could be transplanted into rich Indians and foreigners at many times the fee that the unwitting donors received. At least five foreigners — two U.S. and three Greek citizens — were found in a luxury guesthouse run by the racket in a city of high-tech companies just outside New Delhi.

Demand for cheap kidneys has skyrocketed in recent years in rich countries, mostly because people there are becoming more obese and suffering from kidney failure. This has led to “transplant tourism” where patients from rich countries travel to the developing world to receive new kidneys. It has led to serious proposals to set up a global kidney market to meet the demand.

This black market in kidneys for transplants is widely denounced as illegal and immoral because it exploits poor people. But would creating a worldwide organ trade make the practice any more moral? Is the danger of exploitation of the poor so strong that lawmakers should ensure that money doesn’t end up deciding everything?

This is one of those bioethical challenges that are multiplying as science and technology create situations that were unthinkable not so long ago. Ethics councils, churches and philosophers develop guidelines to keep up, but reality has a way of pulling ahead of them. Globalisation means agents in one country can arrange for patients in a second country to have the transplant performed in a third. We will probably see more rather than fewer cases like this one in Nepal and India.

We’ve written on this issue from several datelines over the past year. Here are a few that give an idea of the problem:

Keen demand fuels global trade in body parts

The who, what, where and why of organ trafficking

Calls for kidney market as transplant demand soars

China, Pakistan bowing to pressure on organ trade

Beijing approves organ transplant hospitals

Human organ trafficking threatens donations schemes

Pakistani gang arrested for stealing kidneys

Here’s the video of the arrest of the Indian suspect in Nepal: