McCabe says his outfit can get a donor from brain death to the operating room in 12 hours. Sometimes it may take an hour after death is declared to obtain consent, the ventilator being kept on while negotiations continue. An hour later, a blood sample is drawn, and it takes eight hours to check for AIDS, hepatitis, and cancer, all of which disqualify a BHC from becoming a donor. Time is of the essence, because the beating-heart cadaver—a brand new kind of creature, known only since the advent of brain death—could easily have a heart attack and die again before his organs are removed. Once a patient goes brain dead, and relatives sign his organ donation consent form, he will get the best medical care of his life. Code blues in hospitals may be a call for doctors to rush to the bedside of beating-heart cadavers who need their hearts defibrillated. BHCs are also routinely turned in their beds so they don’t get bedsores. Their kidneys are treated to avoid renal failure. Fluids are administered constantly to avoid diabetes insipidus, among other things; a healthy BHC should pee out 100 to 250 milliliters of urine per hour. The lungs have to be monitored to keep them in shape for the next owner, and mucous is removed. Steven Ross of Cooper University Hospital in Camden, New Jersey, and Dan Teres of Baystate Medical Center in Springfield, Massachusetts, both say keeping BHCs “alive” is an arduous task for hospital nurses and other workers. Ross says it takes “very aggressive care.” But that they can be medically cared for at all, as Alan Shewmon demonstrated with his 150 cases, gives one pause about the validity of their deaths. There is more than one way to harvest a beating-heart cadaver. McCabe’s outfit uses a team of seven in the operating room: one surgeon, one resident, one technician from the organ bank, one coordinator from the ICU, two nurses, and one anesthesiologist. Some teams may add another surgeon if many organs are being extracted. In a typical dissection, a midline incision is made from just below the neck to the pubic area. The sternum is split with an electric saw or a Lebsche knife, a chisel-like instrument the doctor hits with a mallet. A sternal retractor with spikes is used to open the sternum. Sometimes the aorta is clamped at the beginning of the harvest, and the blood replaced with a coolant to avoid clots and stabilize temperature. Traditionally, the donor’s blood is simply left in place. Mark Schlesinger does not like his patients to feel pain during conventional surgery. He is chairman of the department of anesthesiology at Hackensack University Medical Center in New Jersey, and he points out that an anesthesiologist creates brain-dead patients every day: “We give drugs to make them die. And we bring them back [when the surgery is completed].” A patient under anesthesia is one of the many growing exceptions to the Harvard criteria. He would meet the criteria on the surface, but would be disqualified (ruled still alive) if the examining doctor knew his system was full of drugs. “The only test you fail under anesthesia,” Schlesinger says, “is irreversibility.” That is, if an anesthetized patient has had his brain stem put down temporarily. A brain-dead organ donor’s brain stem is also down—but we do not know, given the limitations of the Harvard criteria and their focus entirely on the brain stem, what is going on with the donor’s cerebral cortex or everything beyond the brain stem. Anesthesiologists have been at the forefront of questioning the finality of brain death and whether beating-heart cadavers truly are unfeeling, unaware corpses. They have also begun wondering about what a “pretty dead” donor may experience during a three- to five-hour harvest sans anesthetic, and they are speaking out on the subject. Gail A. Van Norman, a professor of anesthesiology and bioethics at the University of Washington, cites some disturbing cases.
In one, an anesthesiologist administered a drug to a BHC to treat an episode of tachycardia during a harvest. The donor began to breathe spontaneously just as the surgeon removed his liver. The anesthesiologist reviewed the donor’s chart and found that he had gasped at the end of an apnea test, but a neurosurgeon had declared him dead anyway. In another case, a 30-year-old patient with severe head trauma was declared brain dead by two doctors. Preparations were made to excise his organs. The on-call anesthesiologist noted that the beating-heart cadaver was breathing spontaneously, but the declaring physicians said that because he was not going to recover he could be declared dead. The harvest proceeded over the objections of the anesthesiologist, who saw the donor move and react to the scalpel with hypertension that had to be treated. It was in vain since the proposed liver recipient died before he could get the organ, which went untransplanted. And in a third instance, a young woman suffered seizures several hours after delivering her baby. A neurologist said it was a “catastrophic neurologic event,” and she was readied for harvest. At that time the anesthesiologist found that she had small yet reactive pupils, weak corneal reflexes, and a weak gag reflex. After treatment, “the patient coughed, grimaced, and moved all extremities.” She regained consciousness. She suffered significant neurologic deficits but was alert and oriented.
The brain-death establishment discounts such stories as “anecdotal,” as if they were taken from the National Enquirer. But these three cases appeared in Anesthesiology, the journal of the American Society of Anesthesiologists, which has 44,000 members. The Harvard criteria state that the brain-dead patient must exhibit no movement. Van Norman, however, points out that some exhibit spinal automatism, a complex spectrum of movements including flexion of limbs and trunk, stepping motions, grasping motions, and head turning. Dr. Gregory Liptak, in the Journal of the American Medical Association, wrote: “Patients who are brain dead often have unusual spontaneous movements when they are disconnected from their ventilators…. Goose bumps, shivering, extensor movements of the arms, rapid flexion of the elbows, elevation of the arms above the bed, crossing of the hands, reaching of the hands toward the neck, forced exhalation, and thoracic respiratory-like movements… These complex sequential movements are felt to be release phenomena from the spinal cord including the upper cervical cord and do not [emphasis author’s] mean that the patient is no longer brain dead.” One cannot determine with certainty what organ donors feel, if anything, while being harvested. The logic of brain death goes like this: If the brain stem is dead, then the higher centers of the brain are also probably dead, and if the whole brain is
dead, then everything beneath the brain stem is no longer relevant. Since in practice only the brain stem is routinely tested, the vast majority of the body, everything above the brain stem and everything below, no longer counts as human. The reason for denying beating-heart cadavers anesthetic during the removal of their organs is hard to pin down. (Some experts say it is because anesthetic will harm the organs.) Nevertheless, administering anesthetics to BHCs during organ harvests is becoming more common in Europe, according to Robert Truog, professor of medical ethics, anesthesia, and pediatrics at Harvard Medical School. Despite their strong opposition to brain death, Truog and Shewmon both refuse to acknowledge the possibility that some donors may be in severe pain during organ harvests, even though they acknowledge that some donors did exhibit reactions similar to inadequately anesthetized surgical patients who afterward reported pain and consciousness. Shewmon said the donor reactions were simply “bodily reactions to noxious stimuli.” I asked if an experiment could be designed to answer the question of pain in donors. He said no. Truog did not even want to discuss the possibility of pain in the organ donor. But when I suggested experiments along the lines suggested by other anesthesiologists—when BHCs show pain reactions during a harvest, administer anesthetic to see if the reactions subside—he surprised me by saying he had already done this. He has used two different kinds of anesthetics that do not harm organs to quell symptoms such as high blood pressure or heart rate. “Just because the symptoms come down, though,” he added, “does not mean the patient is in pain. Pain is a subjective thing.” As with Shewmon, I asked Truog if an experiment wasn’t called for. He said there was no experiment that could answer the question of pain in the donor.
Beyond pain, there are many surprising findings in a 1971 paper, “Brain Death: A Clinical and Pathological Study,” published in the Journal of Neurosurgery. The Minnesota team that produced that article studied 25 moribund patients, conducting autopsies on them all and EEGs on some. They also checked for reflexes and found something unusual. Five of the 25 brain-dead people were still sexually responsive. The researchers gently stroked the “nipple and areola” of all patients and got responses from five, four men and one woman. Then they stroked the skin at the root of the penis on the 18 male patients, and four responded with “gentle seesaw movements of the penis.” The researchers felt this reaction was “an incomplete or abortive form of penile erection.” Abortive or not, to the untrained eye it would appear to be a sign of life.
More dramatic are brain-dead pregnant women. The first recorded case occurred in 1981 when a 24-year-old woman, 23 weeks pregnant, was admitted to the Women and Children’s Hospital of Buffalo. After 18 days her EEG showed no cerebral activity and she was transferred to a maternity hospital. A day later she was declared brain dead, approximately 25 weeks pregnant. So she was dead but still pregnant, and doctors decided to use her body—technically it was a corpse—as an incubator. The task was not easy. She developed diabetes insipidus, sinus tachycardia, and uterine contractions. Later she had wide fluctuations in blood pressure, and the fetus’s heart rate was dropping. A cesarean section was performed immediately, delivering a 2-pound “vigorous” baby girl at about the 26th week of gestation. Three months later the infant was discharged from the hospital, weighing about 4.4 pounds.
Six months earlier, another pregnant woman in desperate straits was admitted to the same hospital, with a very different ending. The doctors discontinued life support short of brain death as the fetus was 19 weeks old, and the medical staff accepted the belief that a body could not survive long after brain death was declared. There was theoretically not time to gestate the fetus another 3 weeks, 22 weeks being the earliest a viable baby can be delivered. More brain-dead pregnant moms followed. As of this writing there have been 22 published reports from around the world, including Brazil, Germany, Ireland, New Zealand, France, Finland, Korea, Spain, and the United States. From these 22 brain-dead mothers, 20 babies were produced, with no remarkable side effects in the infants. One woman gestated a fetus for 107 days after declaration of brain death. The real significance of pregnant brain-dead women is that they would seem to sound the death knell for brain death as a definition. As Shewmon and many others have pointed out, what is more indicative of life than gestating a baby to a live and viable birth? Keeping a pregnant mother and baby “alive” for 107 days at the very least puts the lie to the theory that the brain dead will go quickly to conventional heart/lung death. At first, brain death advocates said this is a matter of hours. Then they said 3 to 5 days at the most. Then 7 days, then 9 days, then 14 days. Now we are talking about a brain-dead mother not only hanging on for 107 days but nourishing a baby as well.
A final note: Brain-dead mothers can still donate their organs. And so, after suffering a neurological catastrophe, being declared dead, still having to endure several weeks of pregnancy, then giving birth via cesarean section, the patient can still be rolled off to have her organs removed. A woman’s work is never done.