Blurring the Line Between Life and Death In Organ Donation

The saying goes that nothing is for certain except death and taxes. Dick Teresi invites us to consider that perhaps we aren’t even that certain about death. Of course we all will die, but when we try to pinpoint the moment of death, things get very complicated. Just how complicated is the subject of this book.

In 1968, a group of Harvard scientists published a paper laying out criteria to determine whether a patient is sufficiently unresponsive to be able to declare that an irreversible “loss of personhood” has occurred. This committee began what Teresi refers to as the “brain-death revolution” that reversed millennia of traditional and nearly universal agreement that a body isn’t truly dead until it begins to decay. Given the growing demand for organ donors in the now $5 billion a year transplant enterprise there is pressure to declare potential donor candidates dead earlier and earlier. Teresi suggests that the Harvard Study and its rapid acceptance may have been anticipating this demand.

Overturning traditional consensus isn’t news to anybody alive today, but what is surprising is the lack of good scientific practice in doing so. The original Harvard report cited no studies to support its new criteria. Later studies even falsified their basis. The report switched the debate from biology to philosophy, essentially saying, “We want to redefine death, and here are some suggested criteria for our new definition.” The Harvard report ended up becoming the basis for the 1981 Uniform Determination of Death Act which codified death as the irreversible cessation of the entire brain, but left the medical profession free to formulate how that is determined and gave them immunity from criminal and civil prosecution so long as they act in good faith.

Teresi examines the criteria: being unreceptive and unresponsive, lacking movement or breathing, lacking reflexes, and having a flat electronencephalogram (EEG). Practically, this means just a few simple tests conducted within five minutes at a patient’s bedside: swabbing the eyes to cause a blink, provoking a gag reflex or cough, pouring cold water into the ears, verifying the eyes do not track and then seeing if the patient gasps when disconnected from her respirator. None of the tests by themselves are sufficient upon to review to verify that the person has died.

He compiles an impressive array of falsifying examples that demonstrate that “brain death” maybe a very good predictor of imminent death, but it is by no means an ironclad indicator that an irreversible “loss of personhood” has occurred. These examples range from the beating heart corpses awaiting organ harvest to people in a persistent vegetative state to those having a near death experience, but all of them reveal the tenacious persistence of human life in spite of a loss of measurable brain activity. There exists the very real possibility that many people’s organs are being harvested while they are in fact possessed of some form of consciousness.

Teresi shows how this shift in one part of medicine impacts not only the rest of the art as a whole but also has significant social and legal repercussions. Some of these include doctors who stop treating patients for the sake of saving their organs, hospitals that won’t release bodies to the families until they consent to organ donation, the warehousing of ICU patients, and the complications of carrying out a criminal death sentence.

The final chapter is a look at different philosophical questions in the scientific community which shape the discussion of what death and personhood actually mean. He concludes by clarifying that he is not against organ donation but is simply asking the obvious questions which come from looking at the way it is currently carried out.

By the end it becomes clear why the first chapter is chiefly a reminder that we all will die and there is nothing we can do about it. For all its magnificent accomplishments modern medicine has yet to prevent the eventual death of anyone. In fact, though it has increased the length of time an average person may live (life expectancy) it has been unable even to increase the length of time it is possible for a human being to live (life span). In our rush to preserve life we may have forgotten that it does in one way or another end. Memento mori.

For Teresi, appealing to the brain death criteria is a convenient way for doctors to justify making use of someone who is so close to death that she is otherwise useless. In a sense it avoids the messiness and mystery of human death by bringing it about through organ donation. Teresi shows us that waving the brain death wand doesn’t make the person go away, and that we ought to think more about how to die well than to avoid death.

As a long time science writer and journalist and aware that he, too, is approaching his own death, he is well-suited to issue this call. He takes seriously his obligation to maintain journalistic objectivity but his tone is approachable and full of winsome humor. He doesn’t present the other side strongly, mainly because it already has such broad support. He claims to be making no moral judgments but finds himself constantly pointing out where the emperor of organ donation is lacking some critical garments. His writer’s attention to the semantic battles in brain death reveals their underlying philosophical concerns.

His book’s greatest accomplishment is to show how this shift in the determination of death has nothing to do with biology or scientific advancement but is at root a philosophical judgment that is potentially driven by the economics of organ donation. He could do more, however, to make explicit the Cartesian dualism informing this judgment. Despite its theoretical limitations, the book is worth reading. Teresi writes with the skill of a seasoned journalist, powerfully demonstrating his thesis through a wealth of interviews and compelling stories. The Undead might not lay out a thoroughly philosophical critique of medicine’s morbid interventions, but it will put the reader on alert viscerally. After contemplating Teresi’s vivid and disturbing examples, it is not difficult to see how we should appreciate the mind-body integration now—before our organs are removed.

Benjamin Petty is a seminarian for the Archdiocese of Washington, and received his MTS from the John Paul II Institute for Studies on Marriage and Family in Washington, DC.