By Drs. Jay Boyd and Paul A. Byrne
Published in Homiletic & Pastoral Review OCTOBER 29, 2014
[This essay is based in part on a sermon given in 2010 by an anonymous priest of the FSSP. See the audio link at the end of this article if you wish to listen that sermon.]
It is likely that most Catholics consider the question of the morality of organ donation to be a settled matter, and to view it as a noble and generous gesture on the part of donors. After all, the Catechism of the Catholic Church (CCC) tells us:
Organ transplants are in conformity with the moral law if the physical and psychological dangers and risks to the donor are proportionate to the good sought for the recipient. Organ donation after death is a noble and meritorious act and is to be encouraged as an expression of generous solidarity. It is not morally acceptable if the donor or his proxy has not given explicit consent. Moreover, it is not morally admissible to bring about the disabling mutilation or death of a human being, even in order to delay the death of other persons. (§2296)
A quick scan of this short summary of a complicated topic suggests that there’s nothing wrong with organ donation, as long as the donor gives his consent, and is neither killed, nor sustains disabling mutilation in order to take his organs. Thus, many good Catholics, in the authors’ experience, believe that “the Church says organ donation is okay,” and leave it at that.
However, the picture becomes much more complicated when one considers the transplantation of vital, unpaired organs, such as the heart, or whole liver. The CCC tells us that organ donation in these situations is permitted “after death,” but that phrase requires us to understand what death really is. It is only on examining the way in which death is currently declared, that we discover the horrific problems with organ donation.
Our faith tells us that the moment of separation of the soul from the body is the moment of true death (CCC §1005). Since we cannot observe the separation of the soul from the body, we must rely on other, visible means of determining death.
There are a number of indisputable signs that death has occurred. After death, the body does not respond to stimuli, and it shows significant physical changes observable at the microscopic and gross levels of pathology, manifested by absence of functioning, and in structural alteration. These signs are sufficient to indicate that the life-body unity no longer exists. After death, these pathologic changes continue. They cannot be stopped—only slowed or delayed by cooling, embalming, mummifying, salting, etc.
Prior to advances in organ transplantation, the definition of death was simple, direct, and sensible, as indicated in an article from the New England Journal of Medicine (throughout this essay, emphases added): “Before the development of modern critical care, the diagnosis of death was relatively straightforward. Patients were dead when they were cold, blue, and stiff.”
But these observable signs are not the indications the medical community currently looks for, due to a “redefinition” of death over the last several decades—a redefinition that is due primarily to the fact that “organs from these traditional cadavers (i.e., those bodies that are cold, blue, and stiff, without circulation and respiration) cannot be used for transplantation.” In order for organ transplantation to occur in a legitimately moral sense, death would have to be redefined and the law changed.
Traditionally, the cessation of heartbeat and breathing were regarded as the signs of death. Black’s Law Dictionary defined death as: “The cessation of life; the ceasing to exist; defined by physicians as a total stoppage of the circulation of the blood, and a cessation of the animal and vital functions consequent thereon, such as respiration, pulsation, etc.”This traditional definition of death served an important purpose, even before organ transplants became feasible, though. For instance, some 50 years ago, moral theologian Francis J. Connell, CSSR, was posed a question concerning embalming:
In view of the modern opinion that apparent death (mors apparens) may precede real death (mors vera) by a considerable period of time, what admonition should be given to our people, particularly to Catholic undertakers, as to how soon the process of embalming can be started after a person has apparently breathed his last.
It may seem to be a leap to a different subject to consider the prerequisites for the commencement of embalming, but there are significant parallel issues here with organ donation, so let’s take a look at Fr. Connell’s answer:
The main principle is this: the process of embalming may not be commenced until it is certain that life is extinct, for undoubtedly, if the person is still alive, the embalming process will directly cause death. Furthermore, mere probability, even very great probability, that death is insured will not justify the beginning of this process, for it is not permissible to do anything which even only probably will directly cause the death of an innocent person.
Morally, then: a) the process of embalming may not commence, until it is certain that life is extinct; and b) it is not permissible to do anything which even only probably will directly cause the death of an innocent person.
Now, consider the following situation: Suppose an embalmer begins to make an incision on the body of a (supposedly) deceased person, when suddenly the corpse begins twitching and grimacing. In light of the moral principles stated by Fr. Connell, does it seem reasonable to continue the embalming, as scheduled? Or would it be reasonable to conclude that the proper thing to do would be to give the corpse an anesthetic, so the body would stop twitching, and then continue the embalming? Surely, we would have to answer both questions in the negative; it seems beyond doubt, that if the embalmer continues, a living person would be killed.
If we simply substitute a phrase indicating organ donation in the comments by Fr. Connell, it becomes clear that the transplantation of a vital, unpaired organ is, in reality, an immoral act.
To draw the parallel further, suppose an embalmer is asked to perform the procedure on a body in another room; when the embalmer arrives, he sees that the “corpse” is actually breathing with a ventilator. He has a heartbeat with circulation, has wounds that are healing, and is producing urine. In light of those same moral principles, outlined above, should the embalmer agree to proceed with the embalming, as requested? Obviously the answer is “no,” because to do so would be to definitively kill a human being who shows many signs of life. And yet, this is the condition of most organ donors at the moment that the organs are to be removed and transplanted.
In contrast to the definition of a traditional cadaver, currently there are two basic criteria for determining death: a neurological criterion (in the USA: nonfunctioning of the whole brain, including the brain stem; in the UK: nonfunctioning of the brain stem); and a cardiopulmonary criterion (irreversible cessation of circulatory and respiratory functions).
Let’s consider the cardiopulmonary criterion first. For the physical life of a person to continue, the person must take in oxygen, water, and nutrients. Carbon dioxide is exhaled and waste products are passed in urine and stool. Therefore, ventilation and respiration are required; ventilation is simply the movement of air, while respiration is the exchange of oxygen and carbon dioxide in the lungs, and via circulation in all tissues. Heartbeat, or pulse, is intrinsic to the heart, which has its own nerves that cause heart muscle to contract and stop contracting; the heart beats without impulses from the brain.
If breathing and circulation stop, chest compressions must be initiated quickly, in order for life to continue. Sometimes a ventilator, commonly mislabeled as a respirator, is used. Chest compressions and a ventilator can support respiration in a living person, but not in a cadaver. When such efforts at ventilation and respiration are successful, it is only because the person is living, not dead. In a dead body, air can be forced into the airways and lungs, and elastic recoil might push air out for a few cycles; but then compliance and elastance are lost, and air cannot get in or out. After true death, neither chest compressions, nor a ventilator, can be effective to support ventilation, respiration, and circulation.
Without respiration and circulation, the health of the person deteriorates, and death will occur, unless breathing and circulation are restored quickly. This deterioration is manifest in cessation of vital activities and pathologic changes, such as disintegration, dissolution, lysis, destruction, corruption, decay, and putrefaction of cells and tissues of organs and systems. Thus, the truly dead body cannot be an organ donor, as the vital organs are quickly compromised and begin to deteriorate. On the other hand, a person whose vital organs are functioning, cannot be considered to be truly dead, according to the traditional definition. It is this fact that made it necessary to create a neurological criterion for death—which essentially changes the definition of death.
The history of the “redefinition” of death is rather chilling, when one considers that such redefinitions began evolving as organ transplants became more and more possible and successful. The redefinitions stem from a desire to make use of the organs of someone labeled as “recently deceased,” in order to save the lives of living patients desirous of vital organs as transplants. But as we noted above, a truly deceased person cannot be a suitable organ donor, as his organs no longer have circulation and respiration.
This is where—and why—the neurological definition of death—or “brain death”—comes into play. A patient with heartbeat, respiration, and/or circulation cannot rightly be called a cadaver, a corpse, a dead body. Not coincidentally, prior to true death, patients are sometimes labeled “brain dead” (or sometimes “apparently dead” or “as good as dead”), especially when there is an interest in converting such patients into organ donors. If the label, “probably dead,” or “apparently dead,” (mors apparens) is applied to a potential donor who is not truly dead, he will certainly be truly dead after the beating heart is cut out! As we can see from the Catechism, to take action that will cause death, based on the mere probability that death is about to occur, is a violation of justice.
The medical community, however, continues to struggle with the question of how to “harvest” organs, without appearing to kill the donor in the process. Those who do not hold to a Catholic view of life and/or death seem to view current life-preserving technologies as more of a means for harvesting organs, than for prolonging life. For instance, Crowe and Cohen noted that, in modern times, there are “new problems” associated with defining death:
… in particular, the problem of defining when death has occurred in the age of ventilators and feeding tubes, and how the definition of death (both conceptually, and in practice), shapes the possibility of procuring usable organs from the deceased.
… The reason that the definition of death, and the ethics of organ procurement are so closely linked in the public imagination is that the source of cadaveric organs has always been the newly dead. A newly dead person fulfills two fundamental requirements for being a source of organs. First, he is close enough to the living that his organs have not been so long deprived of oxygen as to become nonfunctional. Second, he is no longer an inviolable subject in the same way: the dead body can be mistreated or wronged, but the dead person cannot experience physical harm.
As heart transplants, in particular, became more desirable and possible, another problem arose: the law requires that the donor of a vital organ—like a heart—be dead before the organ is removed. This is known as the “dead donor law”; and with a standard definition of cardiac death, heart transplants are not possible. Why? Because the definition requires irreversible stoppage of the heartbeat and accompanying respiration. But, as another author has noted:
It is impossible to transplant a heart successfully after irreversible stoppage: if a heart is restarted, the person from whom it was taken cannot have been dead according to cardiac criteria. Removing organs from a patient whose heart, not only can be restarted, but also has been, or will be, restarted in another body, is ending a life by organ removal.
Thus, the concept of “brain death” emerged; 40 years ago, an ad hoc committee at Harvard Medical School suggested revising the definition of death in a way that would make some patients with devastating neurologic injury suitable for organ transplantation under the dead donor rule.
… The concept of brain death has served us well, and has been the ethical and legal justification for thousands of life-saving donation and transplantations. Even so, there have been persistent questions about whether patients with massive brain injury, apnea, and loss of brain stem reflexes are really dead.
This is a striking statement, and one that should give us pause! From the viewpoint of Catholic moral teaching, if there is any question at all, to say nothing of persistentquestions, about whether a patient is really dead, then this is a grave moral problem for the medical community, regarding organ transplantations. The above authors go on to explain why there have been persistent questions about whether or not so-called “brain dead” patients are really dead.
… (W)hen injuries are entirely intracranial, these patients look very much alive. They are warm and pink; they digest and metabolize food; excrete waste; undergo sexual maturation; and can even reproduce. To a casual observer, they look just like patients who are receiving long-term artificial ventilation and are asleep. The arguments about why these patients should be considered dead have never been fully convincing.
This seems to us to be a reflection of the culture of death philosophy that says life is not worth living, once a certain level of physiological dysfunction is reached; it is this philosophy that leads to the advocacy of assisted suicide and euthanasia. Whereas, respect for life tells us that all life—no matter how close it is to death—is sacred, the culture of death tells us that the life of a person as described above is “not worth living”—that the person would be “better off dead.” In a review of a book called Brain Death, we find the following:
Some persons who reliably defined as brain-dead have clinically significant residual functioning as evidenced by electro-encephalographic activity, unexpected survival, attempts to sit up, reproducible eye-opening in response to pain, head movements in response to stimulation. Most perplexing, children who have been given a diagnosis of brain death continue to grow, and pregnant women have delivered healthy infants up to four months after having been given a diagnosis of brain death.
These are, indeed, perplexing observations. How is it possible (as noted above) that “brain dead” children can “continue to grow”? The case of Jahi McMath is one of the most recent stories concerning the questionable diagnosis of “brain death.” This 13-year-old girl was declared legally dead by hospital staff, after suffering complications from a routine tonsillectomy; since “brain death” is the definition of legal death in California, it was the criterion used to pronounce Jahi’s “death.” Dr. Paul Byrne, who has been at the bedside of Jahi, writes that:
Jahi’s heart is beating 100,000 times a day, a rate similar to most persons on earth. … Jahi’s pulse and blood pressure are normal and strong. Jahi digests her food, puts out urine, and has bowel movements. … Jahi’s temperature is 98 with only a blanket to help keep her warm. Her body metabolism keeps her temperature warm. … The only machine used to treat Jahi is a ventilator to push air into her. Jahi pushes the air out. The ventilator is effective only in a living person. The ventilator does not make Jahi’s heart beat. Jahi’s heart has beat naturally without the aid of heart stimulating drugs or a pacemaker more than 15 million times since the Coroner issued a Certificate of Death. What kind of laws do we have?
And yet, doctors have said Jahi McMath is “brain dead,” and Jahi’s mother has had to fight for the legal right to have her daughter receive medical treatment because of this “verdict.”
Similarly, how is it that a woman who has been dead for four months can give birth to a healthy child? Recently, two cases of “brain dead” pregnant women have been in the news. In one case, the woman’s husband asked that his wife be kept on life support in order for the child within her to reach a point in his growth where he would survive birth (and this indeed was accomplished, with the result being the birth of a healthy—if premature—baby boy). In the other case, the husband fought for the legal right to remove his wife from life support, knowing full well that the baby within her would also die. This, too, was accomplished (resulting in the deaths of both mother and baby), under the label of “brain death” of the mother, but the baby was executed when the ventilator for the mother was stopped.
Finally, how is it, as the article cited above noted, that dead people can make “attempts to sit up”? How is it that dead people can have “reproducible eye opening in response to pain”? How is it that dead people can have “head movements in response to stimulation”? How is it that “some persons reliably have clinically significant residual functioning as evidenced by unexpected survival. …”? Unexpected revival might be a better term in some cases: a 2008 LifeSiteNews.com article provides another example of the non-death of a “brain dead” patient:
A Virginia family was shocked, but relieved, when their mother woke up after doctors said she was dead. Fifty-nine-year-old Mrs. Thomas was being kept breathing artificially, with no detectable brain waves for more than 17 hours. The family were discussing organ donation options for their mother, when she suddenly woke up and started speaking to the nurses.
Another case occurred is 2009, and was still under investigation in 2013: Doctors at St. Joseph’s Hospital Health Center (Syracuse, New York) were about to remove organs for transplant from a woman they thought was dead. Then she opened her eyes. She was alive.
It appears that in some circumstances, the passage of time can reverse the diagnosis of brain death, by virtue of the allegedly dead person coming back to life! But time is not always a commodity granted to these patients; in fact, often, time is taken away from them. A statement from the book review mentioned above notes: “With respect to diagnosis (of death) … the observation period can certainly be shortened if a recipient is waiting, and … a second opinion is not recommended because it may jeopardize harvesting of organs.”
According to this source, then, the important thing is not whether or not the donor is actually dead, but rather, avoiding anything (such as a second opinion!) which would jeopardize the transplantation of vital organs. Returning to the Truog and Miller article, we find this telling assertion:
The arguments about why these patients should be considered dead, have never been fully convincing. The definition of brain death requires a complete absence of all functions of the brain, yet many of these patients retain essential neurologic functions. … Some have argued that these patients are dead because they are permanently unconscious, which is true, but if this is the justification, then patients in a permanent vegetative state, who breathe spontaneously, should also be diagnosed as dead, a characterization that most regard as implausible. … Others have claimed that brain dead patients are dead because their brain damage has led to the current cessation of the organism as a whole. Yet evidence shows that, if these patients are supported beyond the acute phase of their illness, which is rarely done, they can survive for many years.
Let us remind ourselves that “traditional cadavers”—those deceased individuals who are cold, blue, and stiff—do not “survive for many years.” In fact, in the case of a traditional cadaver, if it is not embalmed, it must be buried quickly, because it starts to decompose. Decomposition does not occur in a “brain dead” patient.
Truog and Miller come to what they call “the uncomfortable conclusion” that: “… although it may be perfectly ethical to remove vital organs for transplantation from patients who satisfy the diagnostic criterion for brain death, the reason that it is ethical cannot be that we are convinced that they are really dead.”
Frankly, any informed Catholic should disagree that it is “perfectly ethical” to remove organs from such patients, because, clearly, “brain dead” people are not dead. They arenot traditional cadavers. Once their vital organs are removed, then they become traditional cadavers, and then they will become cold, blue, and stiff. It is the removal of their vital organs that kills them.
In a 2001 article on organ transplantation, Bishops Fabian W. Bruskewitz and Robert F. Vasa and their coauthors offer a clear statement of the moral unacceptability of removing vital organs from “brain dead” patients.
All men of good will must properly understand, and explicitly follow, the applicable theologic and moral laws. These laws are: no unpaired, vital organ can be morally removed from a living human person; there should be no commercial traffic in human organs; people, especially the young, must fully comprehend that when they agree to be organ donors, they give transplant surgeons a license to terminate their lives.
… People must fully comprehend that when they agree to be organ donors, they give transplant surgeons a license to terminate their lives. When healthy, vital organs are taken in accordance with the legal common practice of medicine, the donor is killed. The donor is treated and prepared for surgery in a way similar to any living patient going to the operating room. After removal of healthy, vital organs, what is left is an empty corpse. Such removal is ethically unacceptable. It is the removal of the organs that changes the living person to a dead one. It is unethical for transplantation surgeons to continue performing such procedures that mutilate a living human body. These procedures treat the donors as if they were artificially sustained biologic entities, rather than human persons, worthy of dignity and respect. The removal of a healthy, unpaired, vital organ, suitable for transplantation, from someone who has been declared legally “brain dead,” but is not truly, biologically dead, is not ethically acceptable. Evil may not be done, that good might come of it.
On a practical level, we must ask three questions. First of all, what does this mean for those of us who are trying to be faithful soldiers in the Church Militant, and thereby save our immortal souls? In terms of donation, it means that we must not sign any kind of organ donation agreement on the back of our driver’s license or anywhere else. For most people, once the truth is known about organ donation procedures, the definition of “brain death,” and the countless stories of those who have recovered from “brain death,” this is probably a foregone conclusion. Pope John Paul II stated: “Vital organs which occur singly in the body can be removed only after death; that is, from the body of someone who is certainly dead.” Pope Benedict XVI, in similar words, taught: “Individual vital organs cannot be extracted except ex cadavere.” Ex cadavere (Latin) means from a stone cold cadaver—dead, truly dead.
Secondly, what does this mean for the potential recipients of transplanted organs? This is a tougher question, at least on the level of human emotions. Even more common than the stories of “brain dead” people returning to life, are the heartbreaking stories of people who need new hearts, or other vital organs, in order to overcome a life-threatening situation. For instance, known to one of the authors of this essay is a family with three children, who have heart problems that will almost certainly result in their early death. Two of the children have received heart transplants already, and the community has offered much emotional and financial support to the family. In such a situation, the pastor who preaches about the immorality of vital organ transplantation is probably taking his own life in his hands, even amongst his own Catholic flock! It is one thing to tell people not to sign organ donation agreements, because this is a rather impersonal statement, and involves only a hypothetical situation in which the potential donor might find himself at some point. However, it is quite another thing to say that a particular individual should not be the recipient of an ill-gotten organ, because in such a scenario, we may personally know the individual, and the situation is no longer hypothetical. And yet, given what we have reviewed here, in terms of the condition of vital organ donors, it is clear that, no matter what our medical condition, and how dire the straits in which we find ourselves (or our loved ones), we may not accept any sort of transplant organ cut out of one of our “brain dead,” or “cardiac dead,” brothers or sisters.
Thirdly, what does our conclusion mean for those in the medical community? It means that no matter what it may cost them personally and professionally, medical professionals must put these sorts of procedures in the same moral category as tubal ligations, abortions, and contraception, inasmuch as evil may not be done, that good may come of it. “Brain dead” organ donor patients are not dead; they are alive. And when healthy, vital organs are taken out of organ donors, in accordance with the common legal practice of medicine in effect today, the donor is killed.
Why has this become such a difficult issue? In part, the answer lies with the culture of death and a watering-down of Catholic teaching. Besides the obvious emotional tug, especially when children are involved, there is a lack of understanding, even among Catholics, of the salvific value of suffering. This is something that appears to be not often preached, and most people seem to believe that whatever their illness might be, the medical profession ought to be able to cure it, or at least prolong the life of the individual, well into adulthood. Because of this way of thinking, many people would not be willing to forego organ transplants, even if they are told that the donor is not truly dead when the organ is taken. Self-preservation is a natural instinct; and fallen human nature gives us a great capacity for justifying our actions in this regard, and for turning a blind eye to the side of a situation that makes for uncomfortable viewing.
Add to this, the culture of death attitude that downplays, or outright denies, the sanctity of life from true conception until true death. The culture of death also twists words to suit its evil purposes, as we have seen endlessly where the issue of abortion is concerned: people are “pro-choice,” rather than “pro-abortion”; we are faced with “the pregnancy,” as opposed to “the fetus,” or “the baby”; “reproductive rights” are touted, rather than the more honest “abortion on demand.” Similarly, the organ transplant “industry” has found words to obscure the real condition of donor patients; they have simply “redefined” death (that is, they have changed the criteria to declare death) to suit their desires. These new “definitions of death” are contortions of the truth. And they’re killing our brothers and sisters!
This essay is based in part on a sermon given in 2010 by an anonymous priest of the FSSP. The audio file is available at romans10seventeen.org/audio-files/20101114-May-We-Donate-Our-Organs.mp3. A transcription of the actual sermon is available atphilotheaonphire.blogspot.com/p/may-we-donate-our-organs-this-ismy-best.html.