For those who wish the headline was more descriptive: The procedure is called NRP. After a patient is declared dead, they begin recirculating oxygenated blood, but clamp the blood vessels that go...
For those who wish the headline was more descriptive: The procedure is called NRP. After a patient is declared dead, they begin recirculating oxygenated blood, but clamp the blood vessels that go to the brain. This way, organs are not deprived of oxygen before transport.
The controversy comes from the fact that they are essentially reversing the condition that enabled them to declare someone dead in the first place, and there doesn't seem to be a guarantee that no oxygenated blood is making its way back to the brain.
I mean it does say they clamp off the blood vessels leading to the brain. There may be no guarantee that some blood isn’t getting through, but I think there’s a very strong guarantee that they...
I mean it does say they clamp off the blood vessels leading to the brain. There may be no guarantee that some blood isn’t getting through, but I think there’s a very strong guarantee that they can’t possibly be experiencing anything remotely like consciousness.
Yes. I mean, kind of. It takes time for the brain to proceed from "no longer being perfused with oxygenated blood" to "so degraded as to be incapable of consciousness". If you wait that long after...
Do they come back to life or something?
Yes.
I mean, kind of. It takes time for the brain to proceed from "no longer being perfused with oxygenated blood" to "so degraded as to be incapable of consciousness". If you wait that long after cardiac death, the other organs you'd like to harvest for transplant are also degrading. (The brain is by far the body's biggest oxygen hog, so you can get away with a degree of that, but it's not ideal.) It's tough to guarantee that if you introduce mechanical circulation shortly after cardiac death, the brain isn't sufficiently undegraded to "wake up", a condition you really, really don't want to be eviscerating a person in.
If this prompts you to ask "wait, couldn't you do this for someone you didn't want to remain dead", the answer is yes, you can use ECMO for resuscitation, and we sometimes do. The equipment and expertise to do so is rare and expensive, though, and as a general rule, people so deep in asystole that a traditional hospital resuscitation cannot bring them back do not make very good recoveries.
Ultimately, there's a debate here because we have two different sets of criteria for death ("cardiac" and "brain"), they're highly-correlated but not identical (being brain-dead but cardiac-alive being the way more sustainable scenario, as seen from very sad cases that make the news from time to time), and the benchmark set for both isn't truly irreversible in all cases (cardiac death being far more reversible than brain death). In that zone in between, depending on who you ask, a person might be either alive or dead, and the might come out of it (i.e. "be resurrected") under some circumstances.
Thats wild. I had heard of people going brain dead but still physically having their internal organs work. But I had been under the impression that once you go brain dead thats just it and nothing...
Thats wild. I had heard of people going brain dead but still physically having their internal organs work.
But I had been under the impression that once you go brain dead thats just it and nothing could ever bring you back to more than the vegetative state.
I'm not anything even close to a doctor, but it's my understanding that pretty much all you need for at least a short period of some level of consciousness is oxygenated blood going through your...
I'm not anything even close to a doctor, but it's my understanding that pretty much all you need for at least a short period of some level of consciousness is oxygenated blood going through your brain.
I imagine it's deeply unethical to bring back someone's brain after dying, if they were even remotely lucid it would be a horrifying experience.
Maybe it's just because I'm a lay-person with limited knowledge, but reading the article, I don't see the procedures mentioned as too immoral. It might be because I'm viewing the body and person...
Maybe it's just because I'm a lay-person with limited knowledge, but reading the article, I don't see the procedures mentioned as too immoral. It might be because I'm viewing the body and person as separate? They're basically "reviving" the organs, not the person. Even if some oxygen does make it to the brain during the procedure, I don't think it would lead to them miraculously regaining function.
At the point of death for the cases listed in this particular article, the patients seemed unlikely to ever recover. The procedure is done on those who are either ruled brain-dead, or who were at the point of being removed from life support anyway, and thus beyond saving. My bigger concern is doctors calling it quits a bit too early when the patient could potentially recover if left on life support just a day or two longer, but I think that concern exists for all cases.
Thinking of the possibility of oxygen reaching the brain and technically reviving it, I... guess I might see it as something comparable to zombies? We don't consider zombies to be alive the way humans are, they're empty husks. Like I said, I don't think gaining oxygen five minutes after being declared legally dead would be likely to lead to a miraculous full recovery.
I think this is taking a ton of liberties and jumping to a lot of conclusions about how the human brain functions. They'd most likely be considered in a vegetative state or coma if the vessels...
We don't consider zombies to be alive the way humans are, they're empty husks. Like I said, I don't think gaining oxygen five minutes after being declared legally dead would be likely to lead to a miraculous full recovery.
I think this is taking a ton of liberties and jumping to a lot of conclusions about how the human brain functions. They'd most likely be considered in a vegetative state or coma if the vessels weren't clamped. In many of cases of vegetative state there is little to no detectable electrical activity in the an oxygenated brain. We're not even talking about bodies that have regained function of the lungs, or heart. I would imagine oxygenated blood is being circulated with an external pump. They're not going to suddenly regain concessions, or suddenly feel pain. Or somehow become even zombies.
It is a new medical procedure, and much like when surgery is looked at in detail it seems barbaric and scary.
I didn't mean to say they were zombies, it was a passing thought when trying to describe for how I'd perceive any sort of "revival" from the procedure. Like you said, the bodies won't regain...
I didn't mean to say they were zombies, it was a passing thought when trying to describe for how I'd perceive any sort of "revival" from the procedure. Like you said, the bodies won't regain function even if the brain were to get oxygen and thus technically start functioning again. The fact the doctors wait an extra five minutes after declaring the time of death before starting the oxygen process means they'd almost certainly have some form of brain damage, on top of everything else that led to their death. The odds of any sort of miraculous recovery, or even just a regular recovery leading into a vegetable state, are minuscule enough that I don't think it's worth considering.
Hence why I mentioned zombies: the body might seem to be moving and functioning, but the person? They're dead. They're gone and not coming back, the body is essentially just an empty husk. All facsimile of life or function is the result of the body being manipulated by external forces. Maybe a better comparison would be experiments where researchers manually stimulate organs outside of a body, like making a heart beat inside a jar. It's not really functioning in that state, and absolutely no one would argue the original owner is suddenly alive again.
In this case, the organs are just still inside the original body rather than a jar. Which is a massive oversimplification, but I think helps get my point across in terms of how I perceive it. I see this procedure as basically just extending the life of the organs, not the person, which I fully support. (Slightly related: I still feel a bit disappointed my dad was deemed ineligible to be a donor. It would have been a bit of a consolation to know that his death at least led to some good.)
Yeah but does it lead to the person being conscious while you harvest their organs (even if they are doomed that is still a horrific idea). Least from the top comment that seems to be what hte...
Yeah but does it lead to the person being conscious while you harvest their organs (even if they are doomed that is still a horrific idea). Least from the top comment that seems to be what hte concern is.
I appreciate that there are significant, maybe insurmountable, ethical barriers (thanks for posting the details about this @chocobean). However, given the discussion the other day on medically...
I appreciate that there are significant, maybe insurmountable, ethical barriers (thanks for posting the details about this @chocobean).
However, given the discussion the other day on medically assisted euthanasia, I would personally be grateful to have an option to make my (voluntary) death also an optimal organ transplant situation. Given the slippery slope related to consent there, I would not want it to be a thing if it put vulnerable people at risk, but if it were available, I'd definitely do it.
Yeah, and I can definitely respect that. Make it an informed decision for individuals: have that discussion with everyone. Ask them, if you are not expected to make a meaningful recovery, do you...
Yeah, and I can definitely respect that. Make it an informed decision for individuals: have that discussion with everyone. Ask them, if you are not expected to make a meaningful recovery, do you want us to optimize chances for others? And what does meaningful recovery mean for you: that's a whole other can of worms.
I just don't want to see this decision made by doctors on behalf of individuals.
I urge everyone to read the ACP statement (emphases mine)...
I urge everyone to read the ACP statement (emphases mine)
This protocol has been called “NRP-cDCD,” but this name lacks clarity and only describes part of
what is going on. It is more accurately described as organ retrieval after cardiopulmonary arrest
and the induction of brain death. The manner and declaration of death raise significant ethical
questions and concerns.
Ethical Questions and Concerns
First, even though the goal of improving the number and quality of procured organs is an
important one, here, the procedures and the operative definitions used to determine death
seem orchestrated to serve that end. NRP-cDCD appears to violate one of the ethical
foundations of organ donation, the “dead donor rule.” The dead donor rule specifies that
donors cannot be made dead in order to obtain their organs and that organ retrieval cannot
cause death (8,9). It promotes trust in organ transplantation and in medicine more generally by
assuring patients, families, and the public that medicine will center on the individual patient’s
best interests and not just the possible benefit to others, even if the need is great (10).
In NRP-cDCD, the patient is declared dead by the circulatory definition, which requires that
cessation of circulatory and respiratory functions be irreversible (permanent). The intent,
however, is to re-initiate circulation, and the patient is, in fact, successfully resuscitated. The
question arises, does this violate the requirements for declaring death by circulatory criteria?
Then, after declaring circulatory death, the cerebral circulation is deliberately occluded. This
renders the patient brain dead so that circulation can be restored and the patient still beconsidered dead, now by brain death, not circulatory death criteria (11). Death has not taken its
natural course. Brain death has been caused in order to prevent brain reperfusion when
circulation is restored. The purpose seems to be to justify reversing what was supposed to be
irreversible: circulatory death.
The ACP is grasping at straws to oppose NRP. Their argument is... ...that because the already-declared-deceased donor's chest is cracked open (as it would be in a "traditional" organ donor...
The ACP is grasping at straws to oppose NRP.
Their argument is...
It is important to understand what NRP-cDCD entails. After determination of circulatory death,
the donor’s chest is opened (as would normally happen in organ procurement). Recognizing
the potential for restoration of circulation to result in cerebral reperfusion (either directly via
the carotid or vertebral arteries, or indirectly via complex collateral circulations), various
techniques such as ligating arteries or placing intravascular balloons or shunts are used to
prevent cerebral reperfusion and bring on brain death (7). Perfusion is deemed regional,
primarily because circulation to the brain has been actively excluded.
The donor is then quickly connected, via cannulation of large vessels, to an ECMO or bypass
circuit that restores circulation and enables warm perfusion of the organs. This includes the
heart, which may then resume beating. Thus, the determination of irreversibility--necessary for
the certification of death of the patient made moments before--was apparently inaccurate
since circulation is restored. And then, according to one protocol, “standard DBD procurement
will commence” (6), because the patient is now dead by brain death criteria--due to actions
taken by the physicians procuring the organs
...that because the already-declared-deceased donor's chest is cracked open (as it would be in a "traditional" organ donor extraction) and then hooked to ECMO machine that it technically "reverses" the state of being deceased. Donor's heart/circulation stops, be it naturally or by removal of life support, they die. They didn't die because the brain died, they died because their heart/circulation stopped, this seems to be the rub the ACP has a problem with. But it's ignoring the fact that if the heart/circulation stops the brain also dies. They're being nitpicky because an ECMO is a life support machine used on living people to keep them alive; hooking a deceased donor back up to a ECMO isn't bringing them back to life, it's restoring circulation and if they don't block off the blood passages to the brain they risk bringing a donor that would already have brain death due to lack of circulation, "back to life" by doing exactly what the donor doesn't want.
Donors taken off life support will have DNR (do not resuscitate) orders. Hooking a donor to an ECMO and not blocking off the blood to the brain will violate this order and therefor the donor's rights and all the ethical problems therein.
Despite what the ACP is claiming, brain death has not been "caused" by the NRP process. The donor died by circulation death. As a result of circulation death the donor will have brain death. Waiting for there to be irreparable damage to the usable organs in order to meet some arbitrary brain death hurdle is itself unethical and antithetical to the living persons the donor wished to help.
Indeed. I understand Dr Sellers is saving lives using what is, to him, perfectly good materials that will turn into garbage in a few hours. But human beings are not spare cars in a lot, nor are we...
Indeed.
But everyone has to wait a little longer to make sure her breathing doesn’t spontaneously resume within five minutes.
"We good? We good?" Sellers asks.
I understand Dr Sellers is saving lives using what is, to him, perfectly good materials that will turn into garbage in a few hours. But human beings are not spare cars in a lot, nor are we temporarily convenient storage vessels for organs.
A few years ago I was aggressively FOR organ donation. I was the kind of person who called all the agencies I knew to make sure I was properly registered, after we moved to a new province. I remember having a conversation with my priest about it, and I couldn't understand his view at all: I am no longer using my shell, so why not let another soul make use of my shed garbage? His response was that we never truly know when a person crosses over into death, and he felt that if materialist utilisation comes into play, we'd be swayed to "call" it sooner than when it actually happens.
I thought it was a bunch of phooey: brain death is death. But this article points out no you don't have to be brain dead either. And then we have teams of people literally flying in, timer in hand, incessantly asking "we good? We good?" to hack saw out your organs that still has your blood flowing through, still with all the ligaments attached to you. A certain Evangelion scene comes to mind.
We're so far removed from a different way of treating a newly deceased person: having the newly dead family member at home; giving each family member time; cleaning the body together, dressing the body together, combing their hair, holding their hand....
The justification is materialist and utilitarian. This is 0.1 step away from swooping in on freshly dead in poor countries, with justification that the poor country doesnt have good life support anyway, or it costs them too much of their GDP, or the recovery phase will bankrupt the family anyway. Better this way. Here, take $100 we'll take it from here.
Grief is one of the hardest things I've ever dealt with. There are so many parts to the grieving process, and one of those parts is caring for a person's remains in a way that symbolizes just how...
The justification is materialist and utilitarian.
...
I'm taking myself off the list.
Grief is one of the hardest things I've ever dealt with. There are so many parts to the grieving process, and one of those parts is caring for a person's remains in a way that symbolizes just how much they meant to us. You're right: a person's body isn't just a vessel for their organs. A loved one's body is the way we interacted with them throughout their lifespan. It's the arms that comforted us, the heart that beat against our chest, the face that greeted us every time we saw them.
The purpose of organ donation, fundamentally, is to give us more time with our loved ones while they're still alive.
If I do not receive an organ transplant at some point in the next 15 years, I will likely die in my 40s.
Not because I drank too much or ate profligately or did anything at all to worsen my health. (I have lived a very quiet, unexciting life). But a genetic abnormality that I was born with means that I will die if there is no organ transplant waiting for me.
It will be after many years of suffering. My malfunctioning organ will slowly break down and leak poison into my bloodstream. Doctors know extremely little about my condition. There is no treatment for it, nothing to slow it down. The symptoms drive many people into mental illness.
The only cure for me is an organ transplant.
If everyone takes their name off the organ donation lists, my family will get to have a long, gentle goodbye with me--the sort you described in your post.
But they will say goodbye to me in my 40s.
You're right that the description of Dr Sellers' behaviour around the body is crass. But please don't allow one person's poorly chosen words and lack of reverence for the deceased to prompt you to turn your back on organ donation altogether. Sellers' lack of sensitivity doesn't mean you can't treat your loved ones with dignity and respect.
It doesn't mean I won't thank my donor every day and honour their memory for lending me a little more time with the people I love.
Edit: I totally missed chocobean's post about the American College of Physicians' thoughts on NRP. Here is my response with that additional context. I think chocobean raises a good point: I, as a future organ recipient, absolutely do not want an organ from someone who had a good chance at resuscitation--but how high does the probability of resuscitation have to be for us to label a chance "good"?
I've read your post over a few times and I promise you that I am thinking it over very carefully. I do wish very much for you to receive a donor organ very soon, and I do understand that the fewer...
I've read your post over a few times and I promise you that I am thinking it over very carefully. I do wish very much for you to receive a donor organ very soon, and I do understand that the fewer people who opt out due to "ick" the better your chances will be. I also realise that taking organs from an extremely recently alive individual will likely provide the best outcome: I have no objections to others working out a deal with MAID opt in persons to maximize mutually agreed upon happiness and easing of suffering.
But there is a fundamental difference, I believe, in the definition of when I believe i will be dead, and when I will only be perceived to be dead. I am removing the possibility of you receiving an organ that was vivisected from my soon to be dead but as yet living body.
Thank you for clarifying your position. You're totally right in assuming that I wouldn't want an organ from someone with a strong chance at recovery who hopefully would have gone on to many more...
Thank you for clarifying your position. You're totally right in assuming that I wouldn't want an organ from someone with a strong chance at recovery who hopefully would have gone on to many more years of health and happiness. Just the idea of snatching away someone else's chance at resuscitation for my own gain is repulsive.
Let me cop to an embarrassing oversight: I totally missed the comment you posted elsewhere on this topic (your comment with excerpts from the ACP). I thought you were merely making an argument against NRP on the basis that these organ collectors aren't showing the proper reverence for the bodies.
Now that I've seen the ACP statement, I understand how much more complex this situation is than I originally appreciated. I totally agree with this statement from the ACP:
It is tragic when a patient dies awaiting a needed organ. But organ procurement and
transplantation must satisfy ethical standards in meeting this need. NRP-cDCD raises profound
ethical questions regarding the dead donor rule, fundamental ethical obligations of respect,
beneficence, and justice, and the categorical imperative to never use one individual merely as a
means to serve the ends of another, no matter how noble or good those ends may be.
Thank you for your patience and for your willingness to explain your position! You have raised an interesting ethical quandary to my attention. I categorically do not want an organ from someone with a good chance at survival--but at what percentage are the odds at recovery "good enough"?
Something to meditate on. Thank you again for your patience.
Also, let me reassure you that I don't need an organ right this second! If there were abundant donor organs and if transplant were risk-free, I'd probably have a new one sooner rather than later....
I do wish very much for you to receive a donor organ very soon
Also, let me reassure you that I don't need an organ right this second!
If there were abundant donor organs and if transplant were risk-free, I'd probably have a new one sooner rather than later. But because there are so many risks with transplantation and so few organs, and because my symptoms can be managed with medication, I won't be put on a list for another few years.
It's a very strange, very poorly understand condition. I feel terrible for those with a fast progression and those whose symptoms cannot be managed through medication.
Agreed, a human being is not a car in a junkyard or a organ storage vessel. On the other hand, the corpse of an organ donor... Brain death will occur due to loss of circulation. Period. Whether...
I understand Dr Sellers is saving lives using what is, to him, perfectly good materials that will turn into garbage in a few hours. But human beings are not spare cars in a lot, nor are we temporarily convenient storage vessels for organs.
Agreed, a human being is not a car in a junkyard or a organ storage vessel. On the other hand, the corpse of an organ donor...
A few years ago I was aggressively FOR organ donation. I was the kind of person who called all the agencies I knew to make sure I was properly registered, after we moved to a new province. I remember having a conversation with my priest about it, and I couldn't understand his view at all: I am no longer using my shell, so why not let another soul make use of my shed garbage? His response was that we never truly know when a person crosses over into death, and he felt that if materialist utilisation comes into play, we'd be swayed to "call" it sooner than when it actually happens.
I thought it was a bunch of phooey: brain death is death. But this article points out no you don't have to be brain dead either. And then we have teams of people literally flying in, timer in hand, incessantly asking "we good? We good?" to hack saw out your organs that still has your blood flowing through, still with all the ligaments attached to you. A certain Evangelion scene comes to mind.
Brain death will occur due to loss of circulation. Period. Whether the brain stops or the heart stops, it's still death.
You may not like that this person has a sense of urgency because time is of the essence and the death of a donor is literally a life saving act for someone else, but that doesn't make it gruesome or akin to anything you've witnessed in pop culture.
We're so far removed from a different way of treating a newly deceased person: having the newly dead family member at home; giving each family member time; cleaning the body together, dressing the body together, combing their hair, holding their hand....
Which brings up differences in opinion of the deceased vs family. If the donor wants their organs donated then that is something they've prioritized over familial grieving in the presence of their body. Who's wishes are more important, the family's or the donor's?
The justification is materialist and utilitarian. This is 0.1 step away from swooping in on freshly dead in poor countries, with justification that the poor country doesnt have good life support anyway, or it costs them too much of their GDP, or the recovery phase will bankrupt the family anyway. Better this way. Here, take $100 we'll take it from here.
Slippery slope arguments are logical fallacies.
I'm taking myself off the list.
Which is all fine and good for you, since it seems to be your religious beliefs that has an opposition to helping others (we'll ignore the hypocrisy in that here). However, for you or the ACP to decide/recommend that the process itself be stopped because you don't like the idea of someone that has died, often choosing to end their life, will have blood circulated through their body in order to be able to maximize the chance of success of the organ donation they've stated they want to happen is mind boggling.
In what ethical circle is it okay for the ACP to decide what someone else should be allowed to do with their own body after they die? If anything this is completely counter to the ACP's stance on body autonomy in regards to pregnancy/abortion.
I'll admit this one stings a bit. I will assume responsibility for my poor communication. Given my mention of religion in an otherwise scientific discussion of ethics, I could have been more clear...
Which is all fine and good for you, since it seems to be your religious beliefs that has an opposition to helping others (we'll ignore the hypocrisy in that here).
I'll admit this one stings a bit.
I will assume responsibility for my poor communication. Given my mention of religion in an otherwise scientific discussion of ethics, I could have been more clear "no not like that, not like them" instead of assuming a charitable read. And it is also my fault that I didn't demonstrate adequate support and respect and appreciation for the whole donor system and how many lives it changes and saves every single day.
Let me see if I can clarify a bit, but yes I am writing this in a moment of passion, so hypocritically I will beg you for empathy and understanding, and to try and imagine that I'm not some brain-dead heartless monster, with or without religious beliefs.
ex situ alternatives to in situ NRP exist, including hypothermic and normothermic organ reperfusion that can be achieved by machines outside the body. Reperfusion devices can be applied after organs are procured via cDCD without restarting the donor’s circulation or intentionally occluding brain perfusion (15) to render an individual brain dead. More research is needed on these devices. There is a large and ethically significant difference between perfusingan organ versus perfusing an individual. (From the ACP statement)
Please understand I have no issue with donations after DBD (determination of brain death). My priest, that same one, he also has no qualms about donations if say, his head came clean off. But what we are talking about here is cDCD.
If you could assume some decency out of charity here for a moment to wonder at why I, a staunch supporter for DBD organ donation, have issues with cDCD donation to the point of withdrawing consent, knowing I am leaving gifts unsent and folks like @Thales will unfairly be put on the wait for much longer, please give me a minute.
[Thousand word story about my mom redacted]
My mom had a clear Do No Resuscitate order, signed with her long time family doctor, which was clearly expanded to include no heroic measures and no ECMO no MV etc. Which was ignored by other family members. I saw her on ECMO, intubated and on mechanical ventilation, and when they vacuum her tubes I can very clearly see suffering responses. She was young: 51, and her surgeon and doctors all agreed she had a good chance to pull through. Using ECMO gave her another 7 months before she had another stroke at 52, this time her other family members decided to let her wishes be respected and she died.
We all know the chances of making it with CPR are crap. But do we all know that ECMO offers actually quite decent chances, especially for younger patients? If we let someone's heart and lungs rest a bit, there's a good chance the organs kinda take a mini vacation and they can take back the wheel.
If my mom's wishes had been upheld, this was the point where cDCD would have been declared, and the team swoops in, arteries are clamped and my mom would be rendered brain dead from the clamps, and someone else would have had a chance with many many very young and quite good organs.
Blood doesn't flow like an elementary school battery diagram: it's not a single lane highway to the brain and back. What happens to circulation in someone if their leg is amputated? It's a whole network of blood vessels, and blood cells don't just travel through the one lane highway: it finds a way.
What this process is talking about is using machines to circulate blood, in what would usually be a life saving or at least sustaining manner. They know this. That's why they have to specifically clamp main blood vessels to the brain. This clamping action starves the brain until it dies. Then we continue as if DBD had naturally occured. Except it didn't naturally occur.
"The worry is if there were some brain blood flow that certain parts of the brain could potentially continue functioning and then the person wouldn't be dead," says Dr. James Bernat, a professor emeritus of neurology at Dartmouth Geisel School of Medicine. "I don't think it would be conceivable that they would be awake. But from a point of view of 'Is the donor dead or not?' it would require zero blood flow to the brain to prove that."
Families at the hospital don't have the time to sit down and really be educated on what the blurring lines are between living and dead. All they know is that doctors gave a thumbs up or thumbs down. Do regular people signing a DNR realise they're not exempt from all kinds of things done to their body after they're declared dead ?
Take Susie from the article. She lived another week. Cases like that happen about a third of the time, the article says. These are really huge number, among them people who might be alive if the went for the ECMO that their cDCD corpse got. Maybe most of them won't recover or won't event regain consciousness. So what, I lose consciousness every single night but I can still experience pain and I'm still online in some sense.
So what of the time in between? When the major vessels are clamped the brain is slowly deprived of oxygen, and while Dr Sellers is "cracking it open", the person has been declared dead because they're not breathing and circulating on their own. But their brain isn't dead.
Do we know for sure that a person at the brink of death like that doesn't experience sounds and smells and pain, especially if some amount of oxygen passes through smaller vessels into the brain cells? That's the controversy here: if a person is not yet brain dead but they're artificially pumping oxygen rich blood through a system in which still passes some oxygen despite the main vessel being clamped. The article doesn't mention painkillers for the corpse.
People kept on ECMO are alive enough that some of them come back fully alive in the sense of walking talking reasoning laughing etc. These donor candidates are not going to make full recoveries no. But they haven't fully crossed over to the other side. We're talking about rushing in before they're brain dead, and with their heart pumping oxygen to a not yet dead brain.
Should people be able to make that decision? Yes absolutely: informed consent.
Some people might want to sign something that says, if I become vegetative please sedate me and help yourselves. Some people might want to go now with MAID and work out a deal with surgeons for donation. Good for them.
But if I'm injured to the point where I can no longer breath on my own and have no chance for full recovery, if I might still be hovering around in there and some oxygen is keeping me from totally going, I don't want folks to "crack it open" and have at it just yet.
In the interest of trying to eliminate confirmation bias and demonstrate some faith in medical science, what would bring me to a yes again? Check that I'm brain dead. Unhook all the stuff, wait for breathing to stop, then keep checking my brain until even my brain stem is showing no activity. Then I'd died for sure and please, everyone take everything you need.
But they're not doing that are they. They're waiting for someone's heart to stop circulating for five minutes, then they're starting it back up to keep everything fresh.
People make wishes to donate based on "after I've died", usually not "while I'm dying".
If someone is okay with all this, that could be respected. But most people don't know what they're signing up for. They think a declaration of death from two nurses is exactly the same thing as "I can no longer feel or hear and I have fully passed on to the other side or else nothingness".
I'm objective to the part where we treat someone in the process of dying as already a corpse. It might only be a manner of minutes, and willfully ignoring this distinction will indeed save many many lives. But it is this inability to see a human being as a human being, if only for even a few minutes of it being a corpse, and the eagerness for that death to hurry up and happen so that others may live.... and the disappointment when life is even clinging on uselessly with no chance of full recovery for another week....that I find disrespectful and unnatural.
I will apologize in advance in case this comes across as cold hearted, that's not how it is intended, I am just trying to speak clearly and concisely as possible. While I am sure that you/family...
My mom had a clear Do No Resuscitate order, signed with her long time family doctor, which was clearly expanded to include no heroic measures and no ECMO no MV etc. Which was ignored by other family members. I saw her on ECMO, intubated and on mechanical ventilation, and when they vacuum her tubes I can very clearly see suffering responses. She was young: 51, and her surgeon and doctors all agreed she had a good chance to pull through. Using ECMO gave her another 7 months before she had another stroke at 52, this time her other family members decided to let her wishes be respected and she died.
We all know the chances of making it with CPR are crap. But do we all know that ECMO offers actually quite decent chances, especially for younger patients? If we let someone's heart and lungs rest a bit, there's a good chance the organs kinda take a mini vacation and they can take back the wheel.
If my mom's wishes had been upheld, this was the point where cDCD would have been declared, and the team swoops in, arteries are clamped and my mom would be rendered brain dead from the clamps, and someone else would have had a chance with many many very young and quite good organs.
I will apologize in advance in case this comes across as cold hearted, that's not how it is intended, I am just trying to speak clearly and concisely as possible.
While I am sure that you/family valued those extra 7 months in your mother's life, at the end of the day her wishes were cast aside as if the other family members knew better than she did herself, which resulted in some miraculous, but ultimately futile, efforts to barely extend her life and caused her more suffering later because of that disrespect.
If an ECMO is going to keep a patient alive so their organs could have time to recover, it would have been done long before they got to this point where the organ donation team are at the hospital. They aren't keeping an ECMO off to the side telling the patient they can't have it because they're going to use it after they're dead.
What this process is talking about is using machines to circulate blood, in what would usually be a life saving or at least sustaining manner. They know this. That's why they have to specifically clamp main blood vessels to the brain. This clamping action starves the brain until it dies. Then we continue as if DBD had naturally occured. Except it didn't naturally occur.
"The worry is if there were some brain blood flow that certain parts of the brain could potentially continue functioning and then the person wouldn't be dead," says Dr. James Bernat, a professor emeritus of neurology at Dartmouth Geisel School of Medicine. "I don't think it would be conceivable that they would be awake. But from a point of view of 'Is the donor dead or not?' it would require zero blood flow to the brain to prove that."
So what of the time in between? When the major vessels are clamped the brain is slowly deprived of oxygen, and while Dr Sellers is "cracking it open", the person has been declared dead because they're not breathing and circulating on their own. But their brain isn't dead.
Do we know for sure that a person at the brink of death like that doesn't experience sounds and smells and pain, especially if some amount of oxygen passes through smaller vessels into the brain cells? That's the controversy here: if a person is not yet brain dead but they're artificially pumping oxygen rich blood through a system in which still passes some oxygen despite the main vessel being clamped. The article doesn't mention painkillers for the corpse.
In the interest of trying to eliminate confirmation bias and demonstrate some faith in medical science, what would bring me to a yes again? Check that I'm brain dead. Unhook all the stuff, wait for breathing to stop, then keep checking my brain until even my brain stem is showing no activity. Then I'd died for sure and please, everyone take everything you need.
But they're not doing that are they. They're waiting for someone's heart to stop circulating for five minutes, then they're starting it back up to keep everything fresh.
People make wishes to donate based on "after I've died", usually not "while I'm dying".
No one is being cracked open while alive. No one is donating their organs while they're dying. They're dead.
Circulatory death is death. It's not while they're dying. They're not withholding lifesaving measures to harvest organs, this comes after it has already been decided and agreed that nothing can be done to bring the person back to a reasonable quality of life.
Circulatory death leads to brain death. The clamping of the arteries, after circulatory death, feeding blood to the brain isn't causing brain death, the brain is already well on its way to brain death because the circulatory system is dead. At most, and I'm being generous here, the clamping of the arteries is ensuring that the already in-progress process of brain death will continue, as is the wish of the donor, in order to ensure their donation can occur. Stopping the blood flow to the brain of a deceased donor is no different than ex situ donation methods, both are guaranteeing the normal brain death process that would already occur after circulatory death. Being that it is now known that the cells of the brain take hours, if not days, to slowly die, requiring brain death for organ donation would effectively stop all organ donation.
I'm objective to the part where we treat someone in the process of dying as already a corpse. It might only be a manner of minutes, and willfully ignoring this distinction will indeed save many many lives. But it is this inability to see a human being as a human being, if only for even a few minutes of it being a corpse, and the eagerness for that death to hurry up and happen so that others may live.... and the disappointment when life is even clinging on uselessly with no chance of full recovery for another week....that I find disrespectful and unnatural.
I think you're dehumanizing the organ donation team here based on a couple of lines in a news article. They aren't treating someone in the process of dying as a corpse, they don't have an inability to see the human as a human. What they are however, is keenly aware that time is of the essence in order to both save lives and carry out the donor's wishes. Susie's body for example, having lived another week because we humans are resilient creatures, betrayed Susie's choice to be an organ donor. The doctors there for the donation are aware of this and why they were disappointed, as they were unable to provide Susie's donation to save others, and Susie's wishes weren't carried out.
Do you think Susie would have wanted that? If we had the ability to ask questions to Susie after her passing from a traumatic brain injury, to tell her that she's wasn't going to recover from it and that the doctors are going to try to carry out her wish to donate her organs and that it was ultimately unsuccessful as she continued breathing on her own for a week later while in a vegetative state; do you think she'd say "Yeah, that's exactly what I want to happen." - Unlikely. She'd probably be just as disappointed that her desire to make her own passing provide the chance of a fuller life to someone else didn't happen as the doctors that were present.
Thanks for taking the time and having this discussion with me. And you know, I totally agree with you about the rest of my family disrespecting mom's wishes. She gives praises for days she's alive...
Thanks for taking the time and having this discussion with me.
And you know, I totally agree with you about the rest of my family disrespecting mom's wishes. She gives praises for days she's alive some more, and we can observe enjoying of more time with grandchildren, but in those months I never heard her say she was glad her directives were ignored. She knew where I stood on the issue and I never heard her speaking badly of my other family, but I'm sure she made them understand and that's why the next time was the last time. Anyway back to hypotheticals.
Being that it is now known that the cells of the brain take hours, if not days, to slowly die, requiring brain death for organ donation would effectively stop all organ donation.
When I was a child first learning about organ donation, indeed I was not told that the brain takes hours and hours and hours to die. I simply didn't think about the dying process, or to split hairs on the exact moment when someone is dead vs just barely and only technically alive. As it turns out, the whole process takes a while and many factors we don't understand can still steer things one way vs another. We can't even say with any confidence if someone will survive a flu, we speak in likelihoods.
When we talk about organ donation with people, we put emphasis on it being after they're dead. But are we being properly honest here.
Circulatory death is clinical death, it is not the same thing as brain death. We have many people alive and walking and doing normal life things today who have experienced clinical death. The goal post moved and we had to change terminology because science progressed. We used to call clinical death just plain old regular death because it wasn't possible to bring them back. Now we can. Not every time, but with enough regularity that we're not surprised by when it happens anymore.
Not even that long ago someone with "consumption" or significant blood loss or in a vegetative state was considered to be irreversibly on their way to dying. We've moved the definition of death and we'll move it again.
Being declared dead isn't the same thing as the definitive end of life. For me at least. I can see how this is needless waste and foolish ridiculousness for someone who doesn't make that distinction. I mentioned my mother because I observed her clinical death months before she died, and I was there when discussions were held where doctors couldn't tell us one way or the other if more sustaining efforts would lead to recovery or not. Phrases like "she's fighting" and "she's holding on being strong" were thrown around despite her being obviously not even breathing or circulating on her own. The line is very very much murkier and wider than most of us who have not seen it closely can imagine.
If we're going to take organs when we have no chance of recovery, then say that: your organs will be donated when your chances look very very bad. But we're not saying that. We're not even saying your organs will be donated when most of your neurons are still alive.
I want my organs donated when I'm dead. I dont want my organs donated when I've lost chances of recovery. Since the doctors aren't going to make a distinction between the two states, my only option is to withdraw donation request. If we outlaw NRP and make NMP ("Rubbermaid") the standard of care, I'll put myself back on the list.
And we couldn't know what kind of life Susie would have had that week. Maybe she was glad to hear her daughter's voice some more. Maybe she was breathing because she wasn't ready. Maybe she lived that week in regret. Maybe she had no consciousness at all during that week. I just take issue with the casual link between when we cease to observe signs of vigor life vs death. It's like there is this overall assumption that when we lose our faculties we might as well be dead.....I find it diminishing.
Circulatory death is clinical death, agreed. The difference being that the people that are walking around that have been clinically dead are people that were specifically resuscitated because...
Circulatory death is clinical death, agreed.
The difference being that the people that are walking around that have been clinically dead are people that were specifically resuscitated because their chance of recovery was high. These are not the same people that have DNR orders for organ donation. These are two different people in two different scenarios. Being an organ donor isn't going to make healthcare personnel less likely to try to keep you alive.
If we outlaw NRP and make NMP ("Rubbermaid") the standard of care, I'll put myself back on the list.
This is a declaration/hurdle I don't understand. Even if NRP is outlawed and NMP made the standard, it doesn't change the circulatory death/brain death issue you've mentioned. You will still be declared dead upon circulatory death, they will still remove your organs while your brain still has living cells, your brain will still die as it would if NRP was used, the only difference is you are the "Rubbermaid" box instead of an actual plastic box.
Very much in agreement that being on the donor list does not make the healthcare personnel less likely to help, and that the same tech is being used on two different types of people for two...
Very much in agreement that being on the donor list does not make the healthcare personnel less likely to help, and that the same tech is being used on two different types of people for two different outcomes.
On the second point, yes, that is exactly the problem, having my corpse be used as a circulatory pump for someone else's organs. It's crazy sounding isn't it? These used to be my organs until the 5 minute wait, and then my circulation stopped, I have died clinically -- and then I am revived clinically and in definition alive while they remove these organs.
Perhaps a middle ground would be organ donation with a specificity of how the organs can be donated. So you could disallow NRP specifically, while others without your reservations could allow...
Perhaps a middle ground would be organ donation with a specificity of how the organs can be donated. So you could disallow NRP specifically, while others without your reservations could allow such. Similar to DNR orders, they don't have to be blanket "don't try to keep me alive" statements, they can allow certain attempts without allowing "extraordinary" measures to be taken such as being placed on life support/ECMO.
I think in an ideal world that would be a great solution: pull up patient file on an international database, check what's cool an what's not, do as the person in their sound mind and able body...
I think in an ideal world that would be a great solution: pull up patient file on an international database, check what's cool an what's not, do as the person in their sound mind and able body wanted to do.
But as I shared already in this discussion, DNR's are routinely and knowingly violated because no doctor wants to be the one enforcing something the bedside family decides against. There are no Champions by your deathbed you can truly trust to act in your best interests, should those interests coincide with theirs. They have to live with themselves and sometimes the decision they can best live with are the ones they can most easily convince themselves was the right one.
Also, it makes a lot of assumptions about our data and medicine being up to date on stuff like that. (Eye roll) I just got paid all of $7 for LifeLabs losing my private health data. They can't even manage a flu vaccine Rx, I highly doubt within my life time I'll see that level of respectful progress.
But even assuming the best tech, my first point stands : who's going to champion your wishes against the grieving family? Some doctor's gonna come out and stand in front of the OR and bar the door while Mother is inside getting opened up and her corneas gifted to someone else? No way.
Best case scenario, I end up with something terminal and yet has time to make my own prep. Second best, I start doing it now and hope for the best.
Presumably, the champions at your deathbed would be your loved ones who are aware of and respect the choices you made long before it came to that point. That obviously requires conversations that...
Presumably, the champions at your deathbed would be your loved ones who are aware of and respect the choices you made long before it came to that point.
That obviously requires conversations that many people do not want to have, preparations that people do not want to go through, and respect for your wishes to be carried out which, in your mother's case, people do not want to adhere to. It requires a level of maturity and understanding that many people either do not have or are unwilling to address, but they are still individual actions that are miles better than outright ban because a minority of people don't like the idea of NRP.
Yup, totally agree. I can, however, see the fear from no NRP advocates of organ donations. NRP will be used as a bogeyman by anti-donation people to scare everyone off, with the net result of even...
Yup, totally agree.
I can, however, see the fear from no NRP advocates of organ donations. NRP will be used as a bogeyman by anti-donation people to scare everyone off, with the net result of even fewer people opting in and more people who are already on the list opting out (me). Why not abandon the conteoversial NRP and go with the uncontroversial but also very good NMP? Why chase the marginal gain and court controversy instead of embracing and improving NMP so that it can sooner race past the marginal gains of NRP?
It's like cloning etc. Abandon embryonic stem cells and use nose stem cells, suddenly no controversy and better gains
Medical Heath Advocacy is a weird thing....sometimes even when one is informed and has someone awake to speak on your behalf, it's still a toss up and struggle, especially if what you'd like differs from " the usual track ".
If I may, I'd like to try defending this procedure, and hopefully convince you to stay on the list. I understand your discomfort. I fully agree this is a murky ethical problem, and one that should...
I'm taking myself off the list.
If I may, I'd like to try defending this procedure, and hopefully convince you to stay on the list.
I understand your discomfort. I fully agree this is a murky ethical problem, and one that should make us uncomfortable. The lines between death and life are blurry, as is often the case with tough issues such as palliative care, abortion, IVF, assisted suicide, etc. For NRP specifically, I think there are two separate moral considerations to think about here:
1: Is it ethically permissible to conditionally withhold life saving measures?
2: If life saving measures can be withheld, can those same measures be used to save non-brain organs?
One fact that should weigh on our moral consideration isn't disputed: NRP saves lives. NRP results in undeniably alive people receiving life-saving care that they would not have otherwise. Now, if one's answer to #1 is no, then one is fully justified opposing NRP. If your answer to number #1 is yes, then I'd wonder why one would in principle be opposed to #2.
Without NRP, the person still dies. The only end result difference is that organ donors also die unnecessarily. In my view, the ethical problem centers precisely on the efficacy of the head vessel clamps. One may also be opposed to placing the clamps in the first place. It does feel weird: palliative care feels passive where clamps feel like an active measure keeping a person dead. However the head vessel clamps aren't killing the patient; they (assuming they are efficacious) are preventing the patient from receiving life saving measures, which if we agree with #1 shouldn't be a problem.
Now to your credit, if everyone's interests in the room are to remove my organs, that's not a room I want to be in. In intro to ethics courses, a common objection to utilitarianism provided is the killing of an innocent man to harvest his organs to save five lives. This is universally considered a repugnant conclusion, and I can see why one might view this as a similar sort of situation. I think the dis-analogy is the man whose organs are being harvested is already dead.
Yup, you uh, put the clamps right on the head there. (Cough). It wasn't that long ago that we didn't provide ANY pain manage to babies when we operated on them. We argued that since none of us...
In my view, the ethical problem centers precisely on the efficacy of the head vessel clamps.
Yup, you uh, put the clamps right on the head there. (Cough).
It wasn't that long ago that we didn't provide ANY pain manage to babies when we operated on them. We argued that since none of us remember our earliest year, and our nervous systems aren't fully developed anyway = it's all good. We can observe that babies experience pain alright. But we argued that it's difficult to dose anesthesia and anyway outcome will be better if we don't anesthetize, and since there will be no memory of pain and the nervous system isn't able to process it anyway we're providing the best possible care. ("When babies felt no pain", Boston Globe 2017) (archive)
But it wasn’t until 1987 that the American Academy of Pediatrics formally declared it unethical to operate on newborns without anesthetics.[...]
At some point we have to remember that we don't know everything. It wouldn't be the first time this century where we got it wrong on deaths and pain.
This procedure is talking about 5 minutes without fresh oxygen. Is someone's brain totally dead fully within 5 minutes?
However, the amount of time the brain can survive without oxygen before brain damage occurs will vary from person to person. According to the University of California, Santa Barbara’s UCSB ScienceLine website, the brain can withstand three to six minutes without oxygen before brain damage occurs.
So it's possible the brain hasn't been BEGUN to be damaged by the 5 minutr mark when the hack sawing and ripping begins
Regular training can help increase the body’s efficiency concerning oxygen consumption, allowing the brain to last for more extended periods without a fresh oxygen supply. For example, a professional freediver from Spain holds the Guinness World Record of holding his breath for 24 minutes and 3.45 seconds.
The man was able to make diving decisions and move about and experience pain for a full 19 minutes past what these doctors would have declared him dead if he was on a hospital bed.
And we're also talking about clamps which may not even totally cut off oxygen to the brain.
I don't think anyone here is disagreeing with how amazing donor med tech has become and how wonderful and important it is. But I do think we give too little thought of those few minutes between here and there.
How rightfully horrified would we be to one day learn that until the last neuron dies, we still experience being "alive" and maybe even pain?
And anyway no one is debating if we should maximize recipient chances. We already have tech for this!
Normothermic Machine Profusion (NMP) involves taking some blood from the donor’s body and setting up a circulation system for the organ outside the body. The blood is oxygenated and recirculates, dramatic improvements in organ recovery rates.
...
This ongoing debate hinges on whether resuscitation with ECMO that is cut off from the brain constitutes a restoration of cardio-pulmonary function or whether somehow circulation doesn’t “count” unless it includes the brain. At times defenders have appealed to the intention behind the act as key (organ procurement vs saving the patient), but as Glazier and Capron have pointed out, there is nothing in UDDA that references intentions. Death is permanent cessation of cardio-pulmonary function. Regardless of why heart function and circulation are restored, their restoration seems to undermine the claim of death.
...
in NRP, they cut off circulation to the brain knowing you they are going to attempt to restore circulation . If it is the act of cutting off circulation to the brain that is the key to making the patient count as dead, then the proximate cause of death is the act of cutting off circulation to the brain. If, as James Bernat suggests in this issue, the cessation of the functioning of the brain is the true standard of death, then it is the cutting of circulation that does all the work in NRP. One wonders why there is the pretense of waiting for cessation of circulation at all. For any patient where there is a plan to withdraw life support and donate organs, why not just cut off circulation to the brain? Ethically, it is difficult to avoid the conclusion that the teams (and not the underlying disease) are the cause of death of the patient.
If someone signs a donor card and checks off yes if I am on life support and they're going to take it off, please do optimise my recipient chances before you unplug me. Proceed directly to Donor do not stop to collect $200. Good. Wonderful.
But by doing this, as a new tech, we're telling people no we won't take your organs until after you're really and truly dead, with fingers crossed behind our backs and an asterisk on the words "truly dead".
Magnus concludes:
Finally, even if one accepts that NRP patients are dead and that the occlusion to the brain is not the cause of death, there are real questions about the language used to describe the process and the very complicated issues involved in communicating about NRP with the donor’s family members. One approach is simply not to inform families about the process. For example, in one defense of NRP, the authors claimed “Regarding what authorizing families should be told about NRP—Informed consent is not just dumping all details on grieving traumatized families. It requires giving morally relevant information in a sensitive and respectful manner. The technique details of standard deceased organ recovery are not shared with families. Whether families want to know, or need to know, specific NRP techniques, is not known”. This seems to be a plea not to bother grieving families with information that they may find uncomfortable. Others have argued that the language used to describe NRP should be “circumspect.” They recommend not referring to “ECMO” or “recirculation” (and of course no mention of “resuscitation”. Instead, they insist on calling NRP “organ reperfusion.” The idea seems to be to emphasize the organs without any recognition or reference to the fact that the organs are part of the patient’s body at the time that ECMO is initiated.
ECMO is resuscitation. They are resuscitating someone on the verge of death in order to take their organs, but don't worry they're also taking steps to ensure the resuscitation won't stick and they're going to die from oxygen starvation to the brain from clamps. And no we can't wait for brain death before we do all this, organs will spoil. And no even though we can do reperfusion in a Rubber Maid we won't. For the greater good.
It is not hard to see why proponents are NRP are anxious to avoid the risk of clarity. A family has been told that their loved one has a poor prognosis and very little likelihood of surviving. What about options that might rescue them (like ECMO)? They are told their family member is not an ECMO candidate since there is very little chance of the patient recovering while on ECMO. The family is told that the patient is a registered organ donor. Under the terms of First-Person Authorization, organ procurement will move forward. And while they are not an ECMO candidate, they will, in fact, be put on ECMO for organ procurement.
Other families are told that resuscitating a patient will cause harm and recommend making the patient DNR. But the same resuscitation efforts that the family has been persuaded to abandon are then implemented.
Families who are struggling with end-of-life decisions often struggle with the idea that the organs that the teams say don’t work well enough for the patient to recover will actually work for someone else. This is a familiar experience for clinical ethicists and critical care physicians. It is not easy to navigate. NRP is likely to be much more complicated in many cases. What about the patient already on ECMO who is a donor and the decision is made to discontinue ECMO? How will that communication be handled?
A quick rule of thumb in bioethics should be that relying on not telling people what you are doing or attempting to obfuscate with misleading language is a pretty good indication that you are on the wrong track. While some NRP advocates want transparency and complete disclosure, too many leaders and professional organizations have pushed for obfuscation. This is at a minimum a red flag for NRP.
So, please bear with me on this otherwise grotesque thought experiment. Let's imagine that we performed a procedure similar to a lobotomy where brain tissue is destroyed five minutes after the...
Yup, you uh, put the clamps right on the head there. (Cough).
So, please bear with me on this otherwise grotesque thought experiment. Let's imagine that we performed a procedure similar to a lobotomy where brain tissue is destroyed five minutes after the patient dies, then ECMO is applied. Would this resolve your concern with NRP?
This procedure is talking about 5 minutes without fresh oxygen. Is someone's brain totally dead fully within 5 minutes?
Is your concern over whether someone is considered ethically dead at this point? Would you equally object to having vital organs completely removed shortly after death? Just as there isn't a clear line where a fetus becomes a viable human, there similarly doesn't seem to be a clean place biologically to define a person as "dead". However, if no life-saving interventions will be performed, then they seem to me just as dead five minutes post-death as they are an hour post-death, regardless of the level of decay in the brain.
This ethical decision seems complicated by the fact that where we draw this line determines whether other unambiguously alive humans get to live or die; not too dissimilar to cases where pregnancy affects a mother's health (though I agree this isn't entirely analogous.)
ECMO is resuscitation. They are resuscitating someone on the verge of death in order to take their organs, but don't worry they're also taking steps to ensure the resuscitation won't stick and they're going to die from oxygen starvation to the brain from clamps. And no we can't wait for brain death before we do all this, organs will spoil. And no even though we can do reperfusion in a Rubber Maid we won't. For the greater good.
From my original response, this particular section makes it sound like you agree with #1 and disagree with #2? If it is ethically permissible to withhold resuscitation from a patient, then (assuming the clamps work), all the clamps do is withhold resuscitation from the patient, which is #1. Yes, it is crucial that the clamps work, but best I can tell that's not quite what you are objecting to here.
It's also not clear to me that there is any inconsistency with a patient not being a good candidate for ECMO and ECMO being useful to preserve organs for organ donors.
Yes absolutely that would resolve my concern with NRP: decapitate me entirely or better yet ensure as quick of destruction of all my neurons as possible . Its what I do when I go fishing: I make...
So, please bear with me on this otherwise grotesque thought experiment. Let's imagine that we performed a procedure similar to a lobotomy where brain tissue is destroyed five minutes after the patient dies, then ECMO is applied. Would this resolve your concern with NRP?
Yes absolutely that would resolve my concern with NRP: decapitate me entirely or better yet ensure as quick of destruction of all my neurons as possible . Its what I do when I go fishing:
I make sure they are totally and 100% irreversibly still as quickly as possible. Gruesome warning.I don't leave them to suffocate in a bucket of stale sea water. I decapitate. There is a clear distinction to me in those five ten minutes when a fish is gasping and dying vs one that has gone totally still in seconds. If I'm unsure about the twitching I take further steps to destroy the head.
all the clamps do is withhold resuscitation from the patient
I respectfully disagree. If you're talking about resuscitation as in successfully restore oxygen flow to the brain, okay I see it. If I am using resuscitation to mean the efforts in the attempt. I would imagine that is what people who sign DNRs are talking about: they're not saying don't succeed, they're asking for these efforts not to happen to their person, via these efforts not happening to the nexus of their experience of life, aka their bodies. They're looking at CPR or ECMO or MV and making a choice for that not to happen to their bodies. How soon can their bodies no longer belong to them and become common resource? Are we properly having conversations with family about this?
I suspect there isn't anything we disagree on here. If instead of NRP, would the situation be resolved if they just removed the organs from the body at the same point?
Yes absolutely that would resolve my concern with NRP: decapitate me entirely or better yet ensure as quick of destruction of all my neurons as possible.
I suspect there isn't anything we disagree on here.
If I am using resuscitation to mean the efforts in the attempt. I would imagine that is what people who sign DNRs are talking about: they're not saying don't succeed, they're asking for these efforts not to happen to their person, via these efforts not happening to the nexus of their experience of life, aka their bodies.
If instead of NRP, would the situation be resolved if they just removed the organs from the body at the same point?
Yes -- currently they have the technology to remove the organs, remove blood from the same donor, and then keep them flushed with oxygen in a box outside of the body....
Yes -- currently they have the technology to remove the organs, remove blood from the same donor, and then keep them flushed with oxygen in a box outside of the body.
Normothermic Machine Profusion (NMP) involves taking some blood from the donor’s body and setting up a circulation system for the organ outside the body. The blood is oxygenated and recirculates, dramatic improvements in organ recovery rates. New developments and improvements in NMP technology and techniques are continuing to show that NMP can produce impressive results, comparable to the gold standard of organ procurement from patients declared dead by neurological criteria. NMP is promising and ethically uncontroversial.
I have no problem with this method at all whatsoever
First let me say, that I support solutions that reduce moral concern while preserving efficacy, and being a non-medical person, this NMP thing sounds fantastic. I don't mean this disrespectfully,...
Yes -- currently they have the technology to remove the organs, remove blood from the same donor, and then keep them flushed with oxygen in a box outside of the body.
First let me say, that I support solutions that reduce moral concern while preserving efficacy, and being a non-medical person, this NMP thing sounds fantastic.
I don't mean this disrespectfully, I imagine it's just clashing moral intuitions, but I'm struggling to see the morally significant difference between keeping oxygen circling the organs outside of the body vs inside of the body. In a sense, even this distinction as I stated it may be inaccurate since in a way the organs are "the body".
And I think that's certainly why Dr Sellers, and many members commenting or voting on this topic, has such a hard time even understanding why the opponent's are having such a hard time. As you've...
And I think that's certainly why Dr Sellers, and many members commenting or voting on this topic, has such a hard time even understanding why the opponent's are having such a hard time.
As you've said, "The lines between death and life are blurry, as is often the case with tough issues such as palliative care, abortion, IVF, assisted suicide, etc."
I do....think.....that perhaps sometimes we're so sure of our own morality that it's hard to understand someone who can see and agree to all the same exact assertions who then come to a different conclusion as ourselves. 2+2 is 4, so if we can all agree that there's 2 and 2 and we need to add and the equation is 2 + 2 = x, how can it be that someone else came up with 5? They must be mistaken somehow. And we can go in circle reiterating over and over that yes we all agree until it was time to show answers and I have 5 somehow. We might even be tempted to think the other person is stupid, or else their beliefs make them stupid, or wilfully evil somehow. And we have people feeling hurt and angry on both sides.
In this instance, I think that I have come to an understanding of "what is a human being" that is different from my understanding of it when I was younger. I don't want to be thought of as a simpleton who in old age took up religious hogwash in a sheeple way, or else someone who became selfish and conservative now that I'm rich and my days are more numbered. There's more to it than "just" getting red in the face shouting "because it's not right".
I've had more time in recent years to observe what the process of terminal illness looks like on a day to day basis. I've observed what the process of choosing medical options and talking about end of life care looks like. I've had more thoughts about the meaning of each human's life: why are we here, what sustains us, and what happens at either boundaries - when do we become who we are, and when do we transition into death, and do we retain who we are and if so how. How is the body part of us: is the human person a ghost in the shell, or is the body also part of us in a forever sense from before we were born into eternity.
I don't think you're wrong to think what you think. I don't think it's immoral to have come to a different conclusion or to not see why there is any significant difference. And I respect that. But I also think that I might not be the only one who somehow got uncomfortable with something that doesn't seem like it should raise any questions, and I hope that we can respect each other's differences in a sincere way.
Example, if someone wants to take the ashes of their dead cat home and put them in a cute jar on a shelf, we can respect that. If someone threw their dead cat into the city trash compactor but while alive they also loved that cat to pieces to the same degree, maybe we can also respect that. What is the body? What is it to the creature who passed, and what is it to those still living? It's tied up with our individual conceptions of the meaning and coming/goings of life, and we're going to get different answers.b
One quick last question here: it sounds like we are comfortable with restoring circulation and oxygen to the organs outside the body but not inside the body. But what is a body but a collection of...
One quick last question here: it sounds like we are comfortable with restoring circulation and oxygen to the organs outside the body but not inside the body. But what is a body but a collection of organs? How can we even make sense of organs being outside the body if the body is comprised of organs?
I'm comfortable in this bottoming out in differing moral intuitions, which I figured it might, but we shouldn't jump to assuming so (as I'll demonstrate in an upcoming example.) The probing questions are attempts to suss out what exact intuitions are at play, which is important when it motivates our behavior (like whether we donate organs.) I like seeing where intuitions bottom out; it's helpful for understanding both others' perspectives and my own. And it often leads to me changing my mind about issues of morality when I understand the underlying reasons someone has a particular moral belief.
To give an example, if we both believed that life and full moral worth begins at conception, but I believe that IVF is permissible and you tell me IVF is wrong, I'm unlikely to be persuaded. We share moral intuitions, but it isn't obvious to either of us at this point. It would take us having a discussion and me asking probing questions to get to the bottom of why you found IVF to be wrong, and you'd inform me about discarded embryos. At that point, I'd need to either modify my belief in IVF or my belief about embryos to be consistent.
As far as I can tell (and again, I'm still figuring this stuff out), it seems like our moral intuitions are shaped by our environment and experience. I have both dealt with family members receiving palliative care as well as a family member who is only here because they received a viable organ. It's hard to know to what degree my experience biases my intuitions.
I really like this line of inquiry and the spirit of doing so, especially in an environment where the subject might be touchy and so much of it being central to ourselves :) Ah, yes I believe this...
I really like this line of inquiry and the spirit of doing so, especially in an environment where the subject might be touchy and so much of it being central to ourselves :)
But what is a body but a collection of organs?
Ah, yes I believe this statement is one of those, or at least a clue to one
No, a body is not just a collection of organs. As @Thales so eloquently put here:
a person's body isn't just a vessel for their organs. A loved one's body is the way we interacted with them throughout their lifespan. It's the arms that comforted us, the heart that beat against our chest, the face that greeted us every time we saw them.
I grew up materialist, even if it was evangelical materialist. The body, I used to believed, was just dirt. It's dirty in two senses: (1)that it is made of dirt,
[see dialogue from Fullmetal Alchemist:] "Water, 35 litres. Carbon, 20kg. Ammonia, 4 litres. Lime, 1.5kg. Phosperus, 800g. Salt, 250 g. Niter, 100g. Sulphur, 80g. Fluorine, 7.5g. Iron, 5g. Silicon 3g. And fifteen other elements. Those are the elements to make an average adult human body. You can buy these elemental ingredients at the market with the pocket money of a child. Humans are made so cheaply. "
and that it is (2) filthy. It is carnal, it is decaying, and it's what drives violence and gluttony and lust and blah blah blah. Our goals are to put the flesh to death as quickly and thoroughly as we could. Heaven is achieved when we rid ourselves of flesh. Human beings, the earthy, bodily version of us, is something like a dirty rag around a nugget of gold. Like Margaret Atwood wrote in her darkly funny short story Happy Ending,
Inside John, she thinks, is another John, who is much nicer. This other John will emerge like a butterfly from a cocoon, a Jack from a box, a pit from a prune, if the first John is only squeezed enough.
The logical conclusion from a worship without anything to focus on, communion without any physical reality, and a theology that tells us we are totally depraved is that the body is hindering us and we couldn't be rid of it soon enough. If someone else can make use of my shed atoms, all the better.
But something funny happened to me along the way. Eventually, I was no longer a materialist. There's something more to the human experience than the interaction of atoms and the electrical signals in our brains. But, even without all the "woo", if we only take a corpse as the memory keepsake of someone we once loved, then maybe there should still be more love and care and reverence shown to the body.
A corpse didn't feel pain, but loved ones gathering around a very much visibly changed deceased individual can feel pain. A corpse doesn't form new memories, but the family will remember the final goodbye, the wake and the funeral.
I would still prefer a funeral where I'm rolled up in a straw mat and chucked into a hole. No chemicals, no concrete, no metals, scavengers okay. But I'm starting to come around that maybe that would be hurtful for my family. Gist: the human body continues to be something important even after death. Non religious example, I went to my friend's house and I saw two little precious jars on a tall shelf, containing the ashes of his cats. I knew them as M--M-- and D--D--. They're gone now, and my friend doesn't believe he has trapped their spirits or that praying to them grants benefits or anything like that. In fact, if I print off old pictures of his cats and desecrate them in front of my friend, he would feel outraged and hurt, even though the photo shared zero atoms with his cats at any point in time. Photos, bodies, ashes, old favorite toys, or even the house where they frolicked as kittens.... we're not strict materialists when love is involved.
So that's one thing, the body left behind and what's 'proper' because we loved them.
I'd like to gently posit the idea that perhaps people who don't want to donate are not selfish, and perhaps they're not making that decision from lack of love and compassion for others. "Boundaries are a place where we can both love another and ourselves": for some, giving up your entire life and your body to be crucified is within their boundary. For some, gifting time and money while living, and perhaps even living donations of eggs or womb or kidney is within their boundary. But perhaps they can't donate after they die, out of love for their living loved ones. We understand when someone leaves the family vacation home behind to their children, even if there are people in much more dire need of housing.
Much as my friend value our friendship, he will not give me, and nor will I ask for, M--M-- and D--D--'s ashes as fertilizer. My friend isn't selfish for refusing. Even if my plants will die and only magic dead cat ashes will save them. Even if I'm going to die without magic dead cat ashes, it wouldn't be fair to me to think poorly of my friend for refusing.
Even when there are lives on the line, we still have to be careful about making moral or physical claims on what belongs to another person. (Their money and resources are off topic for this discussion. Eat the rich etc. Enforced "sharing" is what killed my grandparents during the Communists revolution: when people believe they have the moral mandate to demand things, anything, from others, sometimes their actions can become extremely cruel and they would still take joy and satisfaction in being cruel, because it lets them feel morally superior. Is taxation a violence is a whole different topic.)
So. Bodies can be sacred. That's one part.
The second part is the transition.
People who take their pets to the vet for euthanasia, they sometimes like to hold the beloved animal as they slowly stop breathing, and slowly grow cold. At what point in time does the pet become just a collection of organs? When is it just twitches, don't worry about the twitches and gasps as we start committing violence to a passing pet's body?
I don't believe there is a an instantaneous moment where life separates from the body. It's not that, one millisecond this creature or person is alive, and the next millisecond they are not alive. Or at least, we don't have the sensibility to see it that distinctly. There's a slow process. If you like, you and I are currently in that broader dying process: the mortality rate on our planet is still effectively 100%, last time I checked.
Which wave marks the lowest tide? When does dawn become day? Or even, when does a boy become a man? Or when does an acquaintance become a true friend? Most of the time, we look back and we can see when we can definitely call it one way vs another -- 10am is definitely day --but the millisecond when it transitioned is harder to pinpoint.
So, maybe you and I agree that we should donate our organs at daybreak. Maybe you decide that's dawn (sun 18° beneathe horizon) and I'm waiting till sunrise (first edge of sun at horizon). Maybe it doesn't make a difference to most people, but what if I do a lot of very important stuff to get ready for my entire day between dawn and sunrise?
I think both of us want to donate our organs out of love for perfect strangers. And I can recognise the desire to max out their advantages as a very loving action. For me, perhaps if I may be a bit self indulgent, giving myself that last ten minutes is also out of an attempt to better love others.
I am a recovering materialist, and when I was a child I used to be a eugenicist as well: people are moving dirty atoms and some of us are obviously worth more than others. It used to be, for me, that the nearly dead should be considered already dead, and no need to shed any tears for what's practical and forward thinking for the rest of us. I used to think that all of our worth is determined by our rationality: when we lose the ability to reason clearly, we are little differentiated from the animals or the dead, to be discounted and if possible, to put to the greatest advantage for others. If there is an afterlife, then the dying process is a sneeze, a coughing fit. Let's ignore it and we'll continue the conversation when you're done with all that. If there isn't an afterlife, well then, our conversation has already ended the moment you couldn't finish your thought. It wasn't psychopathic, it was just "youth" and carelessness. Hopefully.
But I've given stuff like that more thought in recent years. And for me, perhaps only for me because of my previous deficiency, I found that I can better love and care about other people as fully their own worthwhile and meaningful beings, if I take all of their lives more seriously. Over time, I have learned to think less of people in the abstract ("humanity") and more in the solidly concrete way, as real as my own flesh and blood ("human beings"). These are no longer generic pets, they were specific cats called M--M-- and D--D--. They are: even today in little jars or in a picture, they exist in the present tense. There are things that I might find okay in the abstract that are permissible to be done to "cats" that I find are not okay to be done to M--M-- and D--D--. As a result, I seem to be able to empathize more, more able to connect to someone else's grieve even if I don't feel anything myself, more able to share in the joy of someone even if I don't see what there is to be so excited over. I found the worth of the severely handicapped, the unemployed, the drug addict, the elderly, and even the criminal deserving of death.
I think it's admirable that organ donors want to alleviate suffering, to give someone else the gift of health. At one point in time, I signed a document that said, in the extremely unlikely event that I died during this medical procedure, I'd be okay to leave my toddler daughter behind, all so that a stranger can have a shot at having her own children. My gamete recipient did in fact go on to have her own baby, and her life has been immeasurably enriched. But. She's still going to die one day, and my generic kin who is her child is also going to die one day. She still has anxieties, has depression, has fears and sadness and guilt and all those things she had before when she was still waiting for a child. She's gained a lot and overall the existance of a new wonderful person is great -- but none of that changes the fundamental thing about life: it's limited, even with gifts from others.
A gift of organs only prolongs the inevitable in the most wonderful way: it gives us more time, and more vigor to enjoy that extra time. But in the end, having more or less time, more or less enjoyment, isn't the point of life on earth. To alleviate suffering is excellent, but it isn't the most important thing we do here.
So what is it that I can do that's so important in the last ten minutes that wouldnt be more worthwhile turned into a higher probability of success for someone else? If setting out at daybreak is good, why not set out at dawn?
I'm thinking about it. Maybe it's left over from my eugenicist/materialist swing. I was so ready to go away myself and donate everything away when I was young. Then a bunch of life happened and I was dragged kicking and screaming towards "life is worth living to the very very end, even to the last breath, even if someone is severely disabled, even with the experience of horrific evil and abuse, even if they are unconscious, even if going sooner will be better for eveyrone".
There was a Bible verse my mom was very fond of: "
A bruised reed He will not break,
And smoking flax He will not quench, (the prophet Isaiah, quoted by Jesus in Matthew 12:20)
When I was young I thought it was the stupidest thing since creation: the reed will never heal, and indeed grasses just die in an instant anyway. Here today and thrown into a fire tomorrow, as Jesus said. A sputtering wick no longer gives off any light or warmth, and it'll just soot and stink up the house. Better to quench and replace with something new. Right?
My mom started becoming disabled in her forties. She struggled and faught to live to the very end and never asked to have her suffering "alleviated" even as she felt so, so tired and in so much pain and so ready. She left it up to the God who gave her life (and gave her this illness) to decide when to take it up again. And He stubbornly refused to break this battered and very broken reed for 10+ years. What was the point? There was something to it that transcended "suffering avoidance" or "individual comfort/happiness" and was apparently more important even than "maximize group happiness".
I think part of what I learned watching this journey, was that even with all the evil and suffering and terriblness of existence, even though all human life on earth is but a blip at 11:59:59:999 on new year's Eve, is that existence is still worthwhile and better than nonexistence. By grudgingly admitting value to my last ten minutes, I am better able to love others using the (statistical) remaining decades of my life. If the last ten minutes don't matter to me at all, then what's the ten before that, or the hour, or day or the year before? The last ten minutes represent an important edge case of my new worldview, that life, however bent and sputtering and brief, is worthwhile.
But let me stop here and ask: does any of this even make any sense? Can you sort of vaguely see how this might make sense to me right now?
Thanks for taking the time to write this reply. There's a lot to respond to here, as a fellow "recovering" materialist. Though, I'm only not a materialist now because I think the evidence points...
Thanks for taking the time to write this reply.
There's a lot to respond to here, as a fellow "recovering" materialist. Though, I'm only not a materialist now because I think the evidence points to materialism being false. It's a happy accident that this seems to also leave the door open to the existence of value and meaning.
So. Bodies can be sacred. That's one part.
First, I'm totally okay with bodies being sacred. I'm not sure how that gets you to the very specific place where you draw your line, since the organs being donated are just as much the body as anything else, but I think this difference is better illustrated in this next part:
I think both of us want to donate our organs out of love for perfect strangers. And I can recognise the desire to max out their advantages as a very loving action. For me, perhaps if I may be a bit self indulgent, giving myself that last ten minutes is also out of an attempt to better love others.
The quality of these ten minutes are going to be very low: likely either fully unconscious or in pain. Though none of this seems material to our discussion, you seem to be cool with death being defined at the same point the NRP folks do, but want different actions to be taken at that point which I can respect. I think this just bottoms out in differences in moral intuitions. What I will totally agree with is that this is your choice to make, not the government or the doctors.
But let me stop here and ask: does any of this even make any sense? Can you sort of vaguely see how this might make sense to me right now?
I think so, you'll have to correct me if I'm not. I understand the innate desire to cling to this limited life we have. I do respect taking a more embodied approach to how we think of ourselves. If I may, one realization has radically changed my life for the better (and I apologize if I'm getting a little weird here): I don't think there is a self, a "me", that persists moment to moment, and that clinging to this view of personal identity is what causes a great deal of suffering in our world. Realizing the non-existence of the self has been profoundly liberating to me, and radically shaped how I think about morality. We can know this fact about personal identity both rationally through the work of philosophers like David Hume and Daniel Dennett, or experientially through direct observation of our experiences through the work of Buddhists and even folks like Sam Harris.
Ooooh most interesting. perhaps this is getting off topic but I'm fascinated. Kind of like the Egg story, where our current selves are a part of something bigger and more "real"? I don't quite...
Ooooh most interesting. perhaps this is getting off topic but I'm fascinated.
Kind of like the Egg story, where our current selves are a part of something bigger and more "real"? I don't quite understand and I've not read my Hume. But if the self doesn't exist, then I can see how one would be free to make decisions hat benefit others above "oneself"
Meanwhile on the contrary, I believe in the persistence of a self which transcends suffering, and transcends life and death. That what we do / experience here, every second of it, even in extremely limited capacities and circumstances where we are semi or un-conscious, have eternal significance because each of our "self" is eternal.
There are no ordinary people. You have never talked to a mere mortal. Nations, cultures, arts, civilizations - these are mortal, and their life is to ours as the life of a gnat. But it is immortals whom we joke with, work with, marry, snub and exploit - immortal horrors or everlasting splendors. This does not mean that we are to be perpetually solemn. We must play. But our merriment must be of that kind (and it is, in fact, the merriest kind) which exists between people who have, from the outset, taken each other seriously - no flippancy, no superiority, no presumption. (C.S. Lewis, The Weight of Glory)
I appreciate what you had to say, and I think this is a good place to table the discussion, but I am excited to see where our next conversation brings us. As always, it's been a pleasure @chocobean.
I appreciate what you had to say, and I think this is a good place to table the discussion, but I am excited to see where our next conversation brings us. As always, it's been a pleasure @chocobean.
For those who wish the headline was more descriptive: The procedure is called NRP. After a patient is declared dead, they begin recirculating oxygenated blood, but clamp the blood vessels that go to the brain. This way, organs are not deprived of oxygen before transport.
The controversy comes from the fact that they are essentially reversing the condition that enabled them to declare someone dead in the first place, and there doesn't seem to be a guarantee that no oxygenated blood is making its way back to the brain.
I mean it does say they clamp off the blood vessels leading to the brain. There may be no guarantee that some blood isn’t getting through, but I think there’s a very strong guarantee that they can’t possibly be experiencing anything remotely like consciousness.
What is the risk if oxygenated blood makes it back to the brain of a dead person?
Do they come back to life or something?
Yes.
I mean, kind of. It takes time for the brain to proceed from "no longer being perfused with oxygenated blood" to "so degraded as to be incapable of consciousness". If you wait that long after cardiac death, the other organs you'd like to harvest for transplant are also degrading. (The brain is by far the body's biggest oxygen hog, so you can get away with a degree of that, but it's not ideal.) It's tough to guarantee that if you introduce mechanical circulation shortly after cardiac death, the brain isn't sufficiently undegraded to "wake up", a condition you really, really don't want to be eviscerating a person in.
If this prompts you to ask "wait, couldn't you do this for someone you didn't want to remain dead", the answer is yes, you can use ECMO for resuscitation, and we sometimes do. The equipment and expertise to do so is rare and expensive, though, and as a general rule, people so deep in asystole that a traditional hospital resuscitation cannot bring them back do not make very good recoveries.
Ultimately, there's a debate here because we have two different sets of criteria for death ("cardiac" and "brain"), they're highly-correlated but not identical (being brain-dead but cardiac-alive being the way more sustainable scenario, as seen from very sad cases that make the news from time to time), and the benchmark set for both isn't truly irreversible in all cases (cardiac death being far more reversible than brain death). In that zone in between, depending on who you ask, a person might be either alive or dead, and the might come out of it (i.e. "be resurrected") under some circumstances.
Thats wild. I had heard of people going brain dead but still physically having their internal organs work.
But I had been under the impression that once you go brain dead thats just it and nothing could ever bring you back to more than the vegetative state.
I'm not anything even close to a doctor, but it's my understanding that pretty much all you need for at least a short period of some level of consciousness is oxygenated blood going through your brain.
I imagine it's deeply unethical to bring back someone's brain after dying, if they were even remotely lucid it would be a horrifying experience.
Sounds like thise futurama heads in jars.
Maybe it's just because I'm a lay-person with limited knowledge, but reading the article, I don't see the procedures mentioned as too immoral. It might be because I'm viewing the body and person as separate? They're basically "reviving" the organs, not the person. Even if some oxygen does make it to the brain during the procedure, I don't think it would lead to them miraculously regaining function.
At the point of death for the cases listed in this particular article, the patients seemed unlikely to ever recover. The procedure is done on those who are either ruled brain-dead, or who were at the point of being removed from life support anyway, and thus beyond saving. My bigger concern is doctors calling it quits a bit too early when the patient could potentially recover if left on life support just a day or two longer, but I think that concern exists for all cases.
Thinking of the possibility of oxygen reaching the brain and technically reviving it, I... guess I might see it as something comparable to zombies? We don't consider zombies to be alive the way humans are, they're empty husks. Like I said, I don't think gaining oxygen five minutes after being declared legally dead would be likely to lead to a miraculous full recovery.
I think this is taking a ton of liberties and jumping to a lot of conclusions about how the human brain functions. They'd most likely be considered in a vegetative state or coma if the vessels weren't clamped. In many of cases of vegetative state there is little to no detectable electrical activity in the an oxygenated brain. We're not even talking about bodies that have regained function of the lungs, or heart. I would imagine oxygenated blood is being circulated with an external pump. They're not going to suddenly regain concessions, or suddenly feel pain. Or somehow become even zombies.
It is a new medical procedure, and much like when surgery is looked at in detail it seems barbaric and scary.
I didn't mean to say they were zombies, it was a passing thought when trying to describe for how I'd perceive any sort of "revival" from the procedure. Like you said, the bodies won't regain function even if the brain were to get oxygen and thus technically start functioning again. The fact the doctors wait an extra five minutes after declaring the time of death before starting the oxygen process means they'd almost certainly have some form of brain damage, on top of everything else that led to their death. The odds of any sort of miraculous recovery, or even just a regular recovery leading into a vegetable state, are minuscule enough that I don't think it's worth considering.
Hence why I mentioned zombies: the body might seem to be moving and functioning, but the person? They're dead. They're gone and not coming back, the body is essentially just an empty husk. All facsimile of life or function is the result of the body being manipulated by external forces. Maybe a better comparison would be experiments where researchers manually stimulate organs outside of a body, like making a heart beat inside a jar. It's not really functioning in that state, and absolutely no one would argue the original owner is suddenly alive again.
In this case, the organs are just still inside the original body rather than a jar. Which is a massive oversimplification, but I think helps get my point across in terms of how I perceive it. I see this procedure as basically just extending the life of the organs, not the person, which I fully support. (Slightly related: I still feel a bit disappointed my dad was deemed ineligible to be a donor. It would have been a bit of a consolation to know that his death at least led to some good.)
Yeah but does it lead to the person being conscious while you harvest their organs (even if they are doomed that is still a horrific idea). Least from the top comment that seems to be what hte concern is.
I appreciate that there are significant, maybe insurmountable, ethical barriers (thanks for posting the details about this @chocobean).
However, given the discussion the other day on medically assisted euthanasia, I would personally be grateful to have an option to make my (voluntary) death also an optimal organ transplant situation. Given the slippery slope related to consent there, I would not want it to be a thing if it put vulnerable people at risk, but if it were available, I'd definitely do it.
Yeah, and I can definitely respect that. Make it an informed decision for individuals: have that discussion with everyone. Ask them, if you are not expected to make a meaningful recovery, do you want us to optimize chances for others? And what does meaningful recovery mean for you: that's a whole other can of worms.
I just don't want to see this decision made by doctors on behalf of individuals.
I urge everyone to read the ACP statement (emphases mine)
https://www.acponline.org/sites/default/files/documents/clinical_information/resources/end_of_life_care/ethics_determination_of_death_and_organ_transplantation_in_nrp_2021.pdf
The ACP is grasping at straws to oppose NRP.
Their argument is...
...that because the already-declared-deceased donor's chest is cracked open (as it would be in a "traditional" organ donor extraction) and then hooked to ECMO machine that it technically "reverses" the state of being deceased. Donor's heart/circulation stops, be it naturally or by removal of life support, they die. They didn't die because the brain died, they died because their heart/circulation stopped, this seems to be the rub the ACP has a problem with. But it's ignoring the fact that if the heart/circulation stops the brain also dies. They're being nitpicky because an ECMO is a life support machine used on living people to keep them alive; hooking a deceased donor back up to a ECMO isn't bringing them back to life, it's restoring circulation and if they don't block off the blood passages to the brain they risk bringing a donor that would already have brain death due to lack of circulation, "back to life" by doing exactly what the donor doesn't want.
Donors taken off life support will have DNR (do not resuscitate) orders. Hooking a donor to an ECMO and not blocking off the blood to the brain will violate this order and therefor the donor's rights and all the ethical problems therein.
Despite what the ACP is claiming, brain death has not been "caused" by the NRP process. The donor died by circulation death. As a result of circulation death the donor will have brain death. Waiting for there to be irreparable damage to the usable organs in order to meet some arbitrary brain death hurdle is itself unethical and antithetical to the living persons the donor wished to help.
I feel like the answer to that is taking yourself off the organ donor list.
The controversy doesn't seem to be among the donors, but medical ethics boards.
Indeed.
I understand Dr Sellers is saving lives using what is, to him, perfectly good materials that will turn into garbage in a few hours. But human beings are not spare cars in a lot, nor are we temporarily convenient storage vessels for organs.
A few years ago I was aggressively FOR organ donation. I was the kind of person who called all the agencies I knew to make sure I was properly registered, after we moved to a new province. I remember having a conversation with my priest about it, and I couldn't understand his view at all: I am no longer using my shell, so why not let another soul make use of my shed garbage? His response was that we never truly know when a person crosses over into death, and he felt that if materialist utilisation comes into play, we'd be swayed to "call" it sooner than when it actually happens.
I thought it was a bunch of phooey: brain death is death. But this article points out no you don't have to be brain dead either. And then we have teams of people literally flying in, timer in hand, incessantly asking "we good? We good?" to hack saw out your organs that still has your blood flowing through, still with all the ligaments attached to you. A certain Evangelion scene comes to mind.
We're so far removed from a different way of treating a newly deceased person: having the newly dead family member at home; giving each family member time; cleaning the body together, dressing the body together, combing their hair, holding their hand....
The justification is materialist and utilitarian. This is 0.1 step away from swooping in on freshly dead in poor countries, with justification that the poor country doesnt have good life support anyway, or it costs them too much of their GDP, or the recovery phase will bankrupt the family anyway. Better this way. Here, take $100 we'll take it from here.
I'm taking myself off the list.
Grief is one of the hardest things I've ever dealt with. There are so many parts to the grieving process, and one of those parts is caring for a person's remains in a way that symbolizes just how much they meant to us. You're right: a person's body isn't just a vessel for their organs. A loved one's body is the way we interacted with them throughout their lifespan. It's the arms that comforted us, the heart that beat against our chest, the face that greeted us every time we saw them.
You can call organ donation (and methods like NRP) utilitarian--but only, I think, in the sense that they are intended to "maximize happiness and well-being for the affected individuals.".
The purpose of organ donation, fundamentally, is to give us more time with our loved ones while they're still alive.
If I do not receive an organ transplant at some point in the next 15 years, I will likely die in my 40s.
Not because I drank too much or ate profligately or did anything at all to worsen my health. (I have lived a very quiet, unexciting life). But a genetic abnormality that I was born with means that I will die if there is no organ transplant waiting for me.
It will be after many years of suffering. My malfunctioning organ will slowly break down and leak poison into my bloodstream. Doctors know extremely little about my condition. There is no treatment for it, nothing to slow it down. The symptoms drive many people into mental illness.
The only cure for me is an organ transplant.
If everyone takes their name off the organ donation lists, my family will get to have a long, gentle goodbye with me--the sort you described in your post.
But they will say goodbye to me in my 40s.
You're right that the description of Dr Sellers' behaviour around the body is crass. But please don't allow one person's poorly chosen words and lack of reverence for the deceased to prompt you to turn your back on organ donation altogether. Sellers' lack of sensitivity doesn't mean you can't treat your loved ones with dignity and respect.
It doesn't mean I won't thank my donor every day and honour their memory for lending me a little more time with the people I love.
Edit: I totally missed chocobean's post about the American College of Physicians' thoughts on NRP. Here is my response with that additional context. I think chocobean raises a good point: I, as a future organ recipient, absolutely do not want an organ from someone who had a good chance at resuscitation--but how high does the probability of resuscitation have to be for us to label a chance "good"?
I've read your post over a few times and I promise you that I am thinking it over very carefully. I do wish very much for you to receive a donor organ very soon, and I do understand that the fewer people who opt out due to "ick" the better your chances will be. I also realise that taking organs from an extremely recently alive individual will likely provide the best outcome: I have no objections to others working out a deal with MAID opt in persons to maximize mutually agreed upon happiness and easing of suffering.
But there is a fundamental difference, I believe, in the definition of when I believe i will be dead, and when I will only be perceived to be dead. I am removing the possibility of you receiving an organ that was vivisected from my soon to be dead but as yet living body.
Thank you for clarifying your position. You're totally right in assuming that I wouldn't want an organ from someone with a strong chance at recovery who hopefully would have gone on to many more years of health and happiness. Just the idea of snatching away someone else's chance at resuscitation for my own gain is repulsive.
Let me cop to an embarrassing oversight: I totally missed the comment you posted elsewhere on this topic (your comment with excerpts from the ACP). I thought you were merely making an argument against NRP on the basis that these organ collectors aren't showing the proper reverence for the bodies.
Now that I've seen the ACP statement, I understand how much more complex this situation is than I originally appreciated. I totally agree with this statement from the ACP:
Thank you for your patience and for your willingness to explain your position! You have raised an interesting ethical quandary to my attention. I categorically do not want an organ from someone with a good chance at survival--but at what percentage are the odds at recovery "good enough"?
Something to meditate on. Thank you again for your patience.
Also, let me reassure you that I don't need an organ right this second!
If there were abundant donor organs and if transplant were risk-free, I'd probably have a new one sooner rather than later. But because there are so many risks with transplantation and so few organs, and because my symptoms can be managed with medication, I won't be put on a list for another few years.
It's a very strange, very poorly understand condition. I feel terrible for those with a fast progression and those whose symptoms cannot be managed through medication.
Agreed, a human being is not a car in a junkyard or a organ storage vessel. On the other hand, the corpse of an organ donor...
Brain death will occur due to loss of circulation. Period. Whether the brain stops or the heart stops, it's still death.
You may not like that this person has a sense of urgency because time is of the essence and the death of a donor is literally a life saving act for someone else, but that doesn't make it gruesome or akin to anything you've witnessed in pop culture.
Which brings up differences in opinion of the deceased vs family. If the donor wants their organs donated then that is something they've prioritized over familial grieving in the presence of their body. Who's wishes are more important, the family's or the donor's?
Slippery slope arguments are logical fallacies.
Which is all fine and good for you, since it seems to be your religious beliefs that has an opposition to helping others (we'll ignore the hypocrisy in that here). However, for you or the ACP to decide/recommend that the process itself be stopped because you don't like the idea of someone that has died, often choosing to end their life, will have blood circulated through their body in order to be able to maximize the chance of success of the organ donation they've stated they want to happen is mind boggling.
In what ethical circle is it okay for the ACP to decide what someone else should be allowed to do with their own body after they die? If anything this is completely counter to the ACP's stance on body autonomy in regards to pregnancy/abortion.
I'll admit this one stings a bit.
I will assume responsibility for my poor communication. Given my mention of religion in an otherwise scientific discussion of ethics, I could have been more clear "no not like that, not like them" instead of assuming a charitable read. And it is also my fault that I didn't demonstrate adequate support and respect and appreciation for the whole donor system and how many lives it changes and saves every single day.
Let me see if I can clarify a bit, but yes I am writing this in a moment of passion, so hypocritically I will beg you for empathy and understanding, and to try and imagine that I'm not some brain-dead heartless monster, with or without religious beliefs.
Please understand I have no issue with donations after DBD (determination of brain death). My priest, that same one, he also has no qualms about donations if say, his head came clean off. But what we are talking about here is cDCD.
If you could assume some decency out of charity here for a moment to wonder at why I, a staunch supporter for DBD organ donation, have issues with cDCD donation to the point of withdrawing consent, knowing I am leaving gifts unsent and folks like @Thales will unfairly be put on the wait for much longer, please give me a minute.
[Thousand word story about my mom redacted]
My mom had a clear Do No Resuscitate order, signed with her long time family doctor, which was clearly expanded to include no heroic measures and no ECMO no MV etc. Which was ignored by other family members. I saw her on ECMO, intubated and on mechanical ventilation, and when they vacuum her tubes I can very clearly see suffering responses. She was young: 51, and her surgeon and doctors all agreed she had a good chance to pull through. Using ECMO gave her another 7 months before she had another stroke at 52, this time her other family members decided to let her wishes be respected and she died.
We all know the chances of making it with CPR are crap. But do we all know that ECMO offers actually quite decent chances, especially for younger patients? If we let someone's heart and lungs rest a bit, there's a good chance the organs kinda take a mini vacation and they can take back the wheel.
If my mom's wishes had been upheld, this was the point where cDCD would have been declared, and the team swoops in, arteries are clamped and my mom would be rendered brain dead from the clamps, and someone else would have had a chance with many many very young and quite good organs.
Blood doesn't flow like an elementary school battery diagram: it's not a single lane highway to the brain and back. What happens to circulation in someone if their leg is amputated? It's a whole network of blood vessels, and blood cells don't just travel through the one lane highway: it finds a way.
What this process is talking about is using machines to circulate blood, in what would usually be a life saving or at least sustaining manner. They know this. That's why they have to specifically clamp main blood vessels to the brain. This clamping action starves the brain until it dies. Then we continue as if DBD had naturally occured. Except it didn't naturally occur.
Families at the hospital don't have the time to sit down and really be educated on what the blurring lines are between living and dead. All they know is that doctors gave a thumbs up or thumbs down. Do regular people signing a DNR realise they're not exempt from all kinds of things done to their body after they're declared dead ?
Take Susie from the article. She lived another week. Cases like that happen about a third of the time, the article says. These are really huge number, among them people who might be alive if the went for the ECMO that their cDCD corpse got. Maybe most of them won't recover or won't event regain consciousness. So what, I lose consciousness every single night but I can still experience pain and I'm still online in some sense.
So what of the time in between? When the major vessels are clamped the brain is slowly deprived of oxygen, and while Dr Sellers is "cracking it open", the person has been declared dead because they're not breathing and circulating on their own. But their brain isn't dead.
Do we know for sure that a person at the brink of death like that doesn't experience sounds and smells and pain, especially if some amount of oxygen passes through smaller vessels into the brain cells? That's the controversy here: if a person is not yet brain dead but they're artificially pumping oxygen rich blood through a system in which still passes some oxygen despite the main vessel being clamped. The article doesn't mention painkillers for the corpse.
People kept on ECMO are alive enough that some of them come back fully alive in the sense of walking talking reasoning laughing etc. These donor candidates are not going to make full recoveries no. But they haven't fully crossed over to the other side. We're talking about rushing in before they're brain dead, and with their heart pumping oxygen to a not yet dead brain.
Should people be able to make that decision? Yes absolutely: informed consent.
Some people might want to sign something that says, if I become vegetative please sedate me and help yourselves. Some people might want to go now with MAID and work out a deal with surgeons for donation. Good for them.
But if I'm injured to the point where I can no longer breath on my own and have no chance for full recovery, if I might still be hovering around in there and some oxygen is keeping me from totally going, I don't want folks to "crack it open" and have at it just yet.
In the interest of trying to eliminate confirmation bias and demonstrate some faith in medical science, what would bring me to a yes again? Check that I'm brain dead. Unhook all the stuff, wait for breathing to stop, then keep checking my brain until even my brain stem is showing no activity. Then I'd died for sure and please, everyone take everything you need.
But they're not doing that are they. They're waiting for someone's heart to stop circulating for five minutes, then they're starting it back up to keep everything fresh.
People make wishes to donate based on "after I've died", usually not "while I'm dying".
If someone is okay with all this, that could be respected. But most people don't know what they're signing up for. They think a declaration of death from two nurses is exactly the same thing as "I can no longer feel or hear and I have fully passed on to the other side or else nothingness".
I'm objective to the part where we treat someone in the process of dying as already a corpse. It might only be a manner of minutes, and willfully ignoring this distinction will indeed save many many lives. But it is this inability to see a human being as a human being, if only for even a few minutes of it being a corpse, and the eagerness for that death to hurry up and happen so that others may live.... and the disappointment when life is even clinging on uselessly with no chance of full recovery for another week....that I find disrespectful and unnatural.
I will apologize in advance in case this comes across as cold hearted, that's not how it is intended, I am just trying to speak clearly and concisely as possible.
While I am sure that you/family valued those extra 7 months in your mother's life, at the end of the day her wishes were cast aside as if the other family members knew better than she did herself, which resulted in some miraculous, but ultimately futile, efforts to barely extend her life and caused her more suffering later because of that disrespect.
If an ECMO is going to keep a patient alive so their organs could have time to recover, it would have been done long before they got to this point where the organ donation team are at the hospital. They aren't keeping an ECMO off to the side telling the patient they can't have it because they're going to use it after they're dead.
I think you're dehumanizing the organ donation team here based on a couple of lines in a news article. They aren't treating someone in the process of dying as a corpse, they don't have an inability to see the human as a human. What they are however, is keenly aware that time is of the essence in order to both save lives and carry out the donor's wishes. Susie's body for example, having lived another week because we humans are resilient creatures, betrayed Susie's choice to be an organ donor. The doctors there for the donation are aware of this and why they were disappointed, as they were unable to provide Susie's donation to save others, and Susie's wishes weren't carried out.
Do you think Susie would have wanted that? If we had the ability to ask questions to Susie after her passing from a traumatic brain injury, to tell her that she's wasn't going to recover from it and that the doctors are going to try to carry out her wish to donate her organs and that it was ultimately unsuccessful as she continued breathing on her own for a week later while in a vegetative state; do you think she'd say "Yeah, that's exactly what I want to happen." - Unlikely. She'd probably be just as disappointed that her desire to make her own passing provide the chance of a fuller life to someone else didn't happen as the doctors that were present.
Thanks for taking the time and having this discussion with me.
And you know, I totally agree with you about the rest of my family disrespecting mom's wishes. She gives praises for days she's alive some more, and we can observe enjoying of more time with grandchildren, but in those months I never heard her say she was glad her directives were ignored. She knew where I stood on the issue and I never heard her speaking badly of my other family, but I'm sure she made them understand and that's why the next time was the last time. Anyway back to hypotheticals.
When I was a child first learning about organ donation, indeed I was not told that the brain takes hours and hours and hours to die. I simply didn't think about the dying process, or to split hairs on the exact moment when someone is dead vs just barely and only technically alive. As it turns out, the whole process takes a while and many factors we don't understand can still steer things one way vs another. We can't even say with any confidence if someone will survive a flu, we speak in likelihoods.
When we talk about organ donation with people, we put emphasis on it being after they're dead. But are we being properly honest here.
Circulatory death is clinical death, it is not the same thing as brain death. We have many people alive and walking and doing normal life things today who have experienced clinical death. The goal post moved and we had to change terminology because science progressed. We used to call clinical death just plain old regular death because it wasn't possible to bring them back. Now we can. Not every time, but with enough regularity that we're not surprised by when it happens anymore.
Not even that long ago someone with "consumption" or significant blood loss or in a vegetative state was considered to be irreversibly on their way to dying. We've moved the definition of death and we'll move it again.
Being declared dead isn't the same thing as the definitive end of life. For me at least. I can see how this is needless waste and foolish ridiculousness for someone who doesn't make that distinction. I mentioned my mother because I observed her clinical death months before she died, and I was there when discussions were held where doctors couldn't tell us one way or the other if more sustaining efforts would lead to recovery or not. Phrases like "she's fighting" and "she's holding on being strong" were thrown around despite her being obviously not even breathing or circulating on her own. The line is very very much murkier and wider than most of us who have not seen it closely can imagine.
If we're going to take organs when we have no chance of recovery, then say that: your organs will be donated when your chances look very very bad. But we're not saying that. We're not even saying your organs will be donated when most of your neurons are still alive.
I want my organs donated when I'm dead. I dont want my organs donated when I've lost chances of recovery. Since the doctors aren't going to make a distinction between the two states, my only option is to withdraw donation request. If we outlaw NRP and make NMP ("Rubbermaid") the standard of care, I'll put myself back on the list.
And we couldn't know what kind of life Susie would have had that week. Maybe she was glad to hear her daughter's voice some more. Maybe she was breathing because she wasn't ready. Maybe she lived that week in regret. Maybe she had no consciousness at all during that week. I just take issue with the casual link between when we cease to observe signs of vigor life vs death. It's like there is this overall assumption that when we lose our faculties we might as well be dead.....I find it diminishing.
Circulatory death is clinical death, agreed.
The difference being that the people that are walking around that have been clinically dead are people that were specifically resuscitated because their chance of recovery was high. These are not the same people that have DNR orders for organ donation. These are two different people in two different scenarios. Being an organ donor isn't going to make healthcare personnel less likely to try to keep you alive.
This is a declaration/hurdle I don't understand. Even if NRP is outlawed and NMP made the standard, it doesn't change the circulatory death/brain death issue you've mentioned. You will still be declared dead upon circulatory death, they will still remove your organs while your brain still has living cells, your brain will still die as it would if NRP was used, the only difference is you are the "Rubbermaid" box instead of an actual plastic box.
Very much in agreement that being on the donor list does not make the healthcare personnel less likely to help, and that the same tech is being used on two different types of people for two different outcomes.
On the second point, yes, that is exactly the problem, having my corpse be used as a circulatory pump for someone else's organs. It's crazy sounding isn't it? These used to be my organs until the 5 minute wait, and then my circulation stopped, I have died clinically -- and then I am revived clinically and in definition alive while they remove these organs.
Perhaps a middle ground would be organ donation with a specificity of how the organs can be donated. So you could disallow NRP specifically, while others without your reservations could allow such. Similar to DNR orders, they don't have to be blanket "don't try to keep me alive" statements, they can allow certain attempts without allowing "extraordinary" measures to be taken such as being placed on life support/ECMO.
I think in an ideal world that would be a great solution: pull up patient file on an international database, check what's cool an what's not, do as the person in their sound mind and able body wanted to do.
But as I shared already in this discussion, DNR's are routinely and knowingly violated because no doctor wants to be the one enforcing something the bedside family decides against. There are no Champions by your deathbed you can truly trust to act in your best interests, should those interests coincide with theirs. They have to live with themselves and sometimes the decision they can best live with are the ones they can most easily convince themselves was the right one.
Also, it makes a lot of assumptions about our data and medicine being up to date on stuff like that. (Eye roll) I just got paid all of $7 for LifeLabs losing my private health data. They can't even manage a flu vaccine Rx, I highly doubt within my life time I'll see that level of respectful progress.
But even assuming the best tech, my first point stands : who's going to champion your wishes against the grieving family? Some doctor's gonna come out and stand in front of the OR and bar the door while Mother is inside getting opened up and her corneas gifted to someone else? No way.
Best case scenario, I end up with something terminal and yet has time to make my own prep. Second best, I start doing it now and hope for the best.
Presumably, the champions at your deathbed would be your loved ones who are aware of and respect the choices you made long before it came to that point.
That obviously requires conversations that many people do not want to have, preparations that people do not want to go through, and respect for your wishes to be carried out which, in your mother's case, people do not want to adhere to. It requires a level of maturity and understanding that many people either do not have or are unwilling to address, but they are still individual actions that are miles better than outright ban because a minority of people don't like the idea of NRP.
Yup, totally agree.
I can, however, see the fear from no NRP advocates of organ donations. NRP will be used as a bogeyman by anti-donation people to scare everyone off, with the net result of even fewer people opting in and more people who are already on the list opting out (me). Why not abandon the conteoversial NRP and go with the uncontroversial but also very good NMP? Why chase the marginal gain and court controversy instead of embracing and improving NMP so that it can sooner race past the marginal gains of NRP?
It's like cloning etc. Abandon embryonic stem cells and use nose stem cells, suddenly no controversy and better gains
Medical Heath Advocacy is a weird thing....sometimes even when one is informed and has someone awake to speak on your behalf, it's still a toss up and struggle, especially if what you'd like differs from " the usual track ".
If I may, I'd like to try defending this procedure, and hopefully convince you to stay on the list.
I understand your discomfort. I fully agree this is a murky ethical problem, and one that should make us uncomfortable. The lines between death and life are blurry, as is often the case with tough issues such as palliative care, abortion, IVF, assisted suicide, etc. For NRP specifically, I think there are two separate moral considerations to think about here:
1: Is it ethically permissible to conditionally withhold life saving measures?
2: If life saving measures can be withheld, can those same measures be used to save non-brain organs?
One fact that should weigh on our moral consideration isn't disputed: NRP saves lives. NRP results in undeniably alive people receiving life-saving care that they would not have otherwise. Now, if one's answer to #1 is no, then one is fully justified opposing NRP. If your answer to number #1 is yes, then I'd wonder why one would in principle be opposed to #2.
Without NRP, the person still dies. The only end result difference is that organ donors also die unnecessarily. In my view, the ethical problem centers precisely on the efficacy of the head vessel clamps. One may also be opposed to placing the clamps in the first place. It does feel weird: palliative care feels passive where clamps feel like an active measure keeping a person dead. However the head vessel clamps aren't killing the patient; they (assuming they are efficacious) are preventing the patient from receiving life saving measures, which if we agree with #1 shouldn't be a problem.
Now to your credit, if everyone's interests in the room are to remove my organs, that's not a room I want to be in. In intro to ethics courses, a common objection to utilitarianism provided is the killing of an innocent man to harvest his organs to save five lives. This is universally considered a repugnant conclusion, and I can see why one might view this as a similar sort of situation. I think the dis-analogy is the man whose organs are being harvested is already dead.
Yup, you uh, put the clamps right on the head there. (Cough).
It wasn't that long ago that we didn't provide ANY pain manage to babies when we operated on them. We argued that since none of us remember our earliest year, and our nervous systems aren't fully developed anyway = it's all good. We can observe that babies experience pain alright. But we argued that it's difficult to dose anesthesia and anyway outcome will be better if we don't anesthetize, and since there will be no memory of pain and the nervous system isn't able to process it anyway we're providing the best possible care. ("When babies felt no pain", Boston Globe 2017) (archive)
At some point we have to remember that we don't know everything. It wouldn't be the first time this century where we got it wrong on deaths and pain.
This procedure is talking about 5 minutes without fresh oxygen. Is someone's brain totally dead fully within 5 minutes?
So it's possible the brain hasn't been BEGUN to be damaged by the 5 minutr mark when the hack sawing and ripping begins
The man was able to make diving decisions and move about and experience pain for a full 19 minutes past what these doctors would have declared him dead if he was on a hospital bed.
And we're also talking about clamps which may not even totally cut off oxygen to the brain.
I don't think anyone here is disagreeing with how amazing donor med tech has become and how wonderful and important it is. But I do think we give too little thought of those few minutes between here and there.
How rightfully horrified would we be to one day learn that until the last neuron dies, we still experience being "alive" and maybe even pain?
And anyway no one is debating if we should maximize recipient chances. We already have tech for this!
Resuscitating the Dead
NRP and Language from BioEthics Today, 10 June 2024, David Magnus:
...
...
If someone signs a donor card and checks off yes if I am on life support and they're going to take it off, please do optimise my recipient chances before you unplug me. Proceed directly to Donor do not stop to collect $200. Good. Wonderful.
But by doing this, as a new tech, we're telling people no we won't take your organs until after you're really and truly dead, with fingers crossed behind our backs and an asterisk on the words "truly dead".
Magnus concludes:
ECMO is resuscitation. They are resuscitating someone on the verge of death in order to take their organs, but don't worry they're also taking steps to ensure the resuscitation won't stick and they're going to die from oxygen starvation to the brain from clamps. And no we can't wait for brain death before we do all this, organs will spoil. And no even though we can do reperfusion in a Rubber Maid we won't. For the greater good.
So, please bear with me on this otherwise grotesque thought experiment. Let's imagine that we performed a procedure similar to a lobotomy where brain tissue is destroyed five minutes after the patient dies, then ECMO is applied. Would this resolve your concern with NRP?
Is your concern over whether someone is considered ethically dead at this point? Would you equally object to having vital organs completely removed shortly after death? Just as there isn't a clear line where a fetus becomes a viable human, there similarly doesn't seem to be a clean place biologically to define a person as "dead". However, if no life-saving interventions will be performed, then they seem to me just as dead five minutes post-death as they are an hour post-death, regardless of the level of decay in the brain.
This ethical decision seems complicated by the fact that where we draw this line determines whether other unambiguously alive humans get to live or die; not too dissimilar to cases where pregnancy affects a mother's health (though I agree this isn't entirely analogous.)
From my original response, this particular section makes it sound like you agree with #1 and disagree with #2? If it is ethically permissible to withhold resuscitation from a patient, then (assuming the clamps work), all the clamps do is withhold resuscitation from the patient, which is #1. Yes, it is crucial that the clamps work, but best I can tell that's not quite what you are objecting to here.
It's also not clear to me that there is any inconsistency with a patient not being a good candidate for ECMO and ECMO being useful to preserve organs for organ donors.
Yes absolutely that would resolve my concern with NRP: decapitate me entirely or better yet ensure as quick of destruction of all my neurons as possible . Its what I do when I go fishing:
I make sure they are totally and 100% irreversibly still as quickly as possible. Gruesome warning.
I don't leave them to suffocate in a bucket of stale sea water. I decapitate. There is a clear distinction to me in those five ten minutes when a fish is gasping and dying vs one that has gone totally still in seconds. If I'm unsure about the twitching I take further steps to destroy the head.I respectfully disagree. If you're talking about resuscitation as in successfully restore oxygen flow to the brain, okay I see it. If I am using resuscitation to mean the efforts in the attempt. I would imagine that is what people who sign DNRs are talking about: they're not saying don't succeed, they're asking for these efforts not to happen to their person, via these efforts not happening to the nexus of their experience of life, aka their bodies. They're looking at CPR or ECMO or MV and making a choice for that not to happen to their bodies. How soon can their bodies no longer belong to them and become common resource? Are we properly having conversations with family about this?
I suspect there isn't anything we disagree on here.
If instead of NRP, would the situation be resolved if they just removed the organs from the body at the same point?
Yes -- currently they have the technology to remove the organs, remove blood from the same donor, and then keep them flushed with oxygen in a box outside of the body.
https://bioethicstoday.org/blog/resuscitating-the-dead-nrp-and-language/#
I have no problem with this method at all whatsoever
First let me say, that I support solutions that reduce moral concern while preserving efficacy, and being a non-medical person, this NMP thing sounds fantastic.
I don't mean this disrespectfully, I imagine it's just clashing moral intuitions, but I'm struggling to see the morally significant difference between keeping oxygen circling the organs outside of the body vs inside of the body. In a sense, even this distinction as I stated it may be inaccurate since in a way the organs are "the body".
And I think that's certainly why Dr Sellers, and many members commenting or voting on this topic, has such a hard time even understanding why the opponent's are having such a hard time.
As you've said, "The lines between death and life are blurry, as is often the case with tough issues such as palliative care, abortion, IVF, assisted suicide, etc."
I do....think.....that perhaps sometimes we're so sure of our own morality that it's hard to understand someone who can see and agree to all the same exact assertions who then come to a different conclusion as ourselves. 2+2 is 4, so if we can all agree that there's 2 and 2 and we need to add and the equation is 2 + 2 = x, how can it be that someone else came up with 5? They must be mistaken somehow. And we can go in circle reiterating over and over that yes we all agree until it was time to show answers and I have 5 somehow. We might even be tempted to think the other person is stupid, or else their beliefs make them stupid, or wilfully evil somehow. And we have people feeling hurt and angry on both sides.
In this instance, I think that I have come to an understanding of "what is a human being" that is different from my understanding of it when I was younger. I don't want to be thought of as a simpleton who in old age took up religious hogwash in a sheeple way, or else someone who became selfish and conservative now that I'm rich and my days are more numbered. There's more to it than "just" getting red in the face shouting "because it's not right".
I've had more time in recent years to observe what the process of terminal illness looks like on a day to day basis. I've observed what the process of choosing medical options and talking about end of life care looks like. I've had more thoughts about the meaning of each human's life: why are we here, what sustains us, and what happens at either boundaries - when do we become who we are, and when do we transition into death, and do we retain who we are and if so how. How is the body part of us: is the human person a ghost in the shell, or is the body also part of us in a forever sense from before we were born into eternity.
I don't think you're wrong to think what you think. I don't think it's immoral to have come to a different conclusion or to not see why there is any significant difference. And I respect that. But I also think that I might not be the only one who somehow got uncomfortable with something that doesn't seem like it should raise any questions, and I hope that we can respect each other's differences in a sincere way.
Example, if someone wants to take the ashes of their dead cat home and put them in a cute jar on a shelf, we can respect that. If someone threw their dead cat into the city trash compactor but while alive they also loved that cat to pieces to the same degree, maybe we can also respect that. What is the body? What is it to the creature who passed, and what is it to those still living? It's tied up with our individual conceptions of the meaning and coming/goings of life, and we're going to get different answers.b
One quick last question here: it sounds like we are comfortable with restoring circulation and oxygen to the organs outside the body but not inside the body. But what is a body but a collection of organs? How can we even make sense of organs being outside the body if the body is comprised of organs?
I'm comfortable in this bottoming out in differing moral intuitions, which I figured it might, but we shouldn't jump to assuming so (as I'll demonstrate in an upcoming example.) The probing questions are attempts to suss out what exact intuitions are at play, which is important when it motivates our behavior (like whether we donate organs.) I like seeing where intuitions bottom out; it's helpful for understanding both others' perspectives and my own. And it often leads to me changing my mind about issues of morality when I understand the underlying reasons someone has a particular moral belief.
To give an example, if we both believed that life and full moral worth begins at conception, but I believe that IVF is permissible and you tell me IVF is wrong, I'm unlikely to be persuaded. We share moral intuitions, but it isn't obvious to either of us at this point. It would take us having a discussion and me asking probing questions to get to the bottom of why you found IVF to be wrong, and you'd inform me about discarded embryos. At that point, I'd need to either modify my belief in IVF or my belief about embryos to be consistent.
As far as I can tell (and again, I'm still figuring this stuff out), it seems like our moral intuitions are shaped by our environment and experience. I have both dealt with family members receiving palliative care as well as a family member who is only here because they received a viable organ. It's hard to know to what degree my experience biases my intuitions.
I really like this line of inquiry and the spirit of doing so, especially in an environment where the subject might be touchy and so much of it being central to ourselves :)
Ah, yes I believe this statement is one of those, or at least a clue to one
No, a body is not just a collection of organs. As @Thales so eloquently put here:
I grew up materialist, even if it was evangelical materialist. The body, I used to believed, was just dirt. It's dirty in two senses: (1)that it is made of dirt,
[see dialogue from Fullmetal Alchemist:]
"Water, 35 litres. Carbon, 20kg. Ammonia, 4 litres. Lime, 1.5kg. Phosperus, 800g. Salt, 250 g. Niter, 100g. Sulphur, 80g. Fluorine, 7.5g. Iron, 5g. Silicon 3g. And fifteen other elements. Those are the elements to make an average adult human body. You can buy these elemental ingredients at the market with the pocket money of a child. Humans are made so cheaply. "and that it is (2) filthy. It is carnal, it is decaying, and it's what drives violence and gluttony and lust and blah blah blah. Our goals are to put the flesh to death as quickly and thoroughly as we could. Heaven is achieved when we rid ourselves of flesh. Human beings, the earthy, bodily version of us, is something like a dirty rag around a nugget of gold. Like Margaret Atwood wrote in her darkly funny short story Happy Ending,
The logical conclusion from a worship without anything to focus on, communion without any physical reality, and a theology that tells us we are totally depraved is that the body is hindering us and we couldn't be rid of it soon enough. If someone else can make use of my shed atoms, all the better.
But something funny happened to me along the way. Eventually, I was no longer a materialist. There's something more to the human experience than the interaction of atoms and the electrical signals in our brains. But, even without all the "woo", if we only take a corpse as the memory keepsake of someone we once loved, then maybe there should still be more love and care and reverence shown to the body.
A corpse didn't feel pain, but loved ones gathering around a very much visibly changed deceased individual can feel pain. A corpse doesn't form new memories, but the family will remember the final goodbye, the wake and the funeral.
I would still prefer a funeral where I'm rolled up in a straw mat and chucked into a hole. No chemicals, no concrete, no metals, scavengers okay. But I'm starting to come around that maybe that would be hurtful for my family. Gist: the human body continues to be something important even after death. Non religious example, I went to my friend's house and I saw two little precious jars on a tall shelf, containing the ashes of his cats. I knew them as M--M-- and D--D--. They're gone now, and my friend doesn't believe he has trapped their spirits or that praying to them grants benefits or anything like that. In fact, if I print off old pictures of his cats and desecrate them in front of my friend, he would feel outraged and hurt, even though the photo shared zero atoms with his cats at any point in time. Photos, bodies, ashes, old favorite toys, or even the house where they frolicked as kittens.... we're not strict materialists when love is involved.
So that's one thing, the body left behind and what's 'proper' because we loved them.
I'd like to gently posit the idea that perhaps people who don't want to donate are not selfish, and perhaps they're not making that decision from lack of love and compassion for others. "Boundaries are a place where we can both love another and ourselves": for some, giving up your entire life and your body to be crucified is within their boundary. For some, gifting time and money while living, and perhaps even living donations of eggs or womb or kidney is within their boundary. But perhaps they can't donate after they die, out of love for their living loved ones. We understand when someone leaves the family vacation home behind to their children, even if there are people in much more dire need of housing.
Much as my friend value our friendship, he will not give me, and nor will I ask for, M--M-- and D--D--'s ashes as fertilizer. My friend isn't selfish for refusing. Even if my plants will die and only magic dead cat ashes will save them. Even if I'm going to die without magic dead cat ashes, it wouldn't be fair to me to think poorly of my friend for refusing.
Even when there are lives on the line, we still have to be careful about making moral or physical claims on what belongs to another person. (Their money and resources are off topic for this discussion. Eat the rich etc. Enforced "sharing" is what killed my grandparents during the Communists revolution: when people believe they have the moral mandate to demand things, anything, from others, sometimes their actions can become extremely cruel and they would still take joy and satisfaction in being cruel, because it lets them feel morally superior. Is taxation a violence is a whole different topic.)
So. Bodies can be sacred. That's one part.
The second part is the transition.
People who take their pets to the vet for euthanasia, they sometimes like to hold the beloved animal as they slowly stop breathing, and slowly grow cold. At what point in time does the pet become just a collection of organs? When is it just twitches, don't worry about the twitches and gasps as we start committing violence to a passing pet's body?
I don't believe there is a an instantaneous moment where life separates from the body. It's not that, one millisecond this creature or person is alive, and the next millisecond they are not alive. Or at least, we don't have the sensibility to see it that distinctly. There's a slow process. If you like, you and I are currently in that broader dying process: the mortality rate on our planet is still effectively 100%, last time I checked.
Which wave marks the lowest tide? When does dawn become day? Or even, when does a boy become a man? Or when does an acquaintance become a true friend? Most of the time, we look back and we can see when we can definitely call it one way vs another -- 10am is definitely day --but the millisecond when it transitioned is harder to pinpoint.
So, maybe you and I agree that we should donate our organs at daybreak. Maybe you decide that's dawn (sun 18° beneathe horizon) and I'm waiting till sunrise (first edge of sun at horizon). Maybe it doesn't make a difference to most people, but what if I do a lot of very important stuff to get ready for my entire day between dawn and sunrise?
I think both of us want to donate our organs out of love for perfect strangers. And I can recognise the desire to max out their advantages as a very loving action. For me, perhaps if I may be a bit self indulgent, giving myself that last ten minutes is also out of an attempt to better love others.
I am a recovering materialist, and when I was a child I used to be a eugenicist as well: people are moving dirty atoms and some of us are obviously worth more than others. It used to be, for me, that the nearly dead should be considered already dead, and no need to shed any tears for what's practical and forward thinking for the rest of us. I used to think that all of our worth is determined by our rationality: when we lose the ability to reason clearly, we are little differentiated from the animals or the dead, to be discounted and if possible, to put to the greatest advantage for others. If there is an afterlife, then the dying process is a sneeze, a coughing fit. Let's ignore it and we'll continue the conversation when you're done with all that. If there isn't an afterlife, well then, our conversation has already ended the moment you couldn't finish your thought. It wasn't psychopathic, it was just "youth" and carelessness. Hopefully.
But I've given stuff like that more thought in recent years. And for me, perhaps only for me because of my previous deficiency, I found that I can better love and care about other people as fully their own worthwhile and meaningful beings, if I take all of their lives more seriously. Over time, I have learned to think less of people in the abstract ("humanity") and more in the solidly concrete way, as real as my own flesh and blood ("human beings"). These are no longer generic pets, they were specific cats called M--M-- and D--D--. They are: even today in little jars or in a picture, they exist in the present tense. There are things that I might find okay in the abstract that are permissible to be done to "cats" that I find are not okay to be done to M--M-- and D--D--. As a result, I seem to be able to empathize more, more able to connect to someone else's grieve even if I don't feel anything myself, more able to share in the joy of someone even if I don't see what there is to be so excited over. I found the worth of the severely handicapped, the unemployed, the drug addict, the elderly, and even the criminal deserving of death.
I think it's admirable that organ donors want to alleviate suffering, to give someone else the gift of health. At one point in time, I signed a document that said, in the extremely unlikely event that I died during this medical procedure, I'd be okay to leave my toddler daughter behind, all so that a stranger can have a shot at having her own children. My gamete recipient did in fact go on to have her own baby, and her life has been immeasurably enriched. But. She's still going to die one day, and my generic kin who is her child is also going to die one day. She still has anxieties, has depression, has fears and sadness and guilt and all those things she had before when she was still waiting for a child. She's gained a lot and overall the existance of a new wonderful person is great -- but none of that changes the fundamental thing about life: it's limited, even with gifts from others.
A gift of organs only prolongs the inevitable in the most wonderful way: it gives us more time, and more vigor to enjoy that extra time. But in the end, having more or less time, more or less enjoyment, isn't the point of life on earth. To alleviate suffering is excellent, but it isn't the most important thing we do here.
So what is it that I can do that's so important in the last ten minutes that wouldnt be more worthwhile turned into a higher probability of success for someone else? If setting out at daybreak is good, why not set out at dawn?
I'm thinking about it. Maybe it's left over from my eugenicist/materialist swing. I was so ready to go away myself and donate everything away when I was young. Then a bunch of life happened and I was dragged kicking and screaming towards "life is worth living to the very very end, even to the last breath, even if someone is severely disabled, even with the experience of horrific evil and abuse, even if they are unconscious, even if going sooner will be better for eveyrone".
There was a Bible verse my mom was very fond of: "
When I was young I thought it was the stupidest thing since creation: the reed will never heal, and indeed grasses just die in an instant anyway. Here today and thrown into a fire tomorrow, as Jesus said. A sputtering wick no longer gives off any light or warmth, and it'll just soot and stink up the house. Better to quench and replace with something new. Right?
My mom started becoming disabled in her forties. She struggled and faught to live to the very end and never asked to have her suffering "alleviated" even as she felt so, so tired and in so much pain and so ready. She left it up to the God who gave her life (and gave her this illness) to decide when to take it up again. And He stubbornly refused to break this battered and very broken reed for 10+ years. What was the point? There was something to it that transcended "suffering avoidance" or "individual comfort/happiness" and was apparently more important even than "maximize group happiness".
I think part of what I learned watching this journey, was that even with all the evil and suffering and terriblness of existence, even though all human life on earth is but a blip at 11:59:59:999 on new year's Eve, is that existence is still worthwhile and better than nonexistence. By grudgingly admitting value to my last ten minutes, I am better able to love others using the (statistical) remaining decades of my life. If the last ten minutes don't matter to me at all, then what's the ten before that, or the hour, or day or the year before? The last ten minutes represent an important edge case of my new worldview, that life, however bent and sputtering and brief, is worthwhile.
But let me stop here and ask: does any of this even make any sense? Can you sort of vaguely see how this might make sense to me right now?
Thanks for taking the time to write this reply.
There's a lot to respond to here, as a fellow "recovering" materialist. Though, I'm only not a materialist now because I think the evidence points to materialism being false. It's a happy accident that this seems to also leave the door open to the existence of value and meaning.
First, I'm totally okay with bodies being sacred. I'm not sure how that gets you to the very specific place where you draw your line, since the organs being donated are just as much the body as anything else, but I think this difference is better illustrated in this next part:
The quality of these ten minutes are going to be very low: likely either fully unconscious or in pain. Though none of this seems material to our discussion, you seem to be cool with death being defined at the same point the NRP folks do, but want different actions to be taken at that point which I can respect. I think this just bottoms out in differences in moral intuitions. What I will totally agree with is that this is your choice to make, not the government or the doctors.
I think so, you'll have to correct me if I'm not. I understand the innate desire to cling to this limited life we have. I do respect taking a more embodied approach to how we think of ourselves. If I may, one realization has radically changed my life for the better (and I apologize if I'm getting a little weird here): I don't think there is a self, a "me", that persists moment to moment, and that clinging to this view of personal identity is what causes a great deal of suffering in our world. Realizing the non-existence of the self has been profoundly liberating to me, and radically shaped how I think about morality. We can know this fact about personal identity both rationally through the work of philosophers like David Hume and Daniel Dennett, or experientially through direct observation of our experiences through the work of Buddhists and even folks like Sam Harris.
Ooooh most interesting. perhaps this is getting off topic but I'm fascinated.
Kind of like the Egg story, where our current selves are a part of something bigger and more "real"? I don't quite understand and I've not read my Hume. But if the self doesn't exist, then I can see how one would be free to make decisions hat benefit others above "oneself"
Meanwhile on the contrary, I believe in the persistence of a self which transcends suffering, and transcends life and death. That what we do / experience here, every second of it, even in extremely limited capacities and circumstances where we are semi or un-conscious, have eternal significance because each of our "self" is eternal.
I appreciate what you had to say, and I think this is a good place to table the discussion, but I am excited to see where our next conversation brings us. As always, it's been a pleasure @chocobean.