Brain-dead: medical morality in the non-western world

HI 269Week 20

Determining death: how can we tell that life has ended?

• Putrefaction

• Body is cold and dry, not warm and moist

• Cessation of breath

• Cessation of heartbeat and/or pulse

• Cessation of brain activity

Life, death & ‘the Romeo error’

Photo of c. 1890 Burial vaults, Popular Mechanics Magazine, 1921 (wikimedia commons, http://en.wikipedia.org/wiki/File:Premature_Burial_Vault.JPG accessed 8/03/09)

Life after breath: Impact of the Iron Lung

Impact of the Iron Lung/ artificial respirators

• Separation of ‘breath’ from ‘life’, stoppage of breathing from death

• Separation of heart beat from ‘life’, lack of heart-beat from ‘death’

Western response:“Obsolete criteria for the definition of death can

lead to controversy in obtaining organs for transplantation.”

‘Ad Hoc Committee of the Harvard Medical School to examine the definition of death’ JAMA 1968

“As the need for donors grows larger, the definition of death must be carefully redefined. When are you

dead enough to be deprived of your heart?” The Nation

(Smith 1968:721).

“In my opinion the clinician can become too pre-occupied with the rights of the

dead, namely the donor, at the expense of the recipient. We should not

jeopardize the possible survival of the recipient while we are waiting around to made a decision whether the cadaver,

as you call it, is dead or not.”

Dr Cooley, US transplant surgeon, at July 1968 conference organised by Barnard

“A neocortical death standard [that is, a standard based in irreversible loss of consciousness and

cognition] could significantly increase availability and access to transplants because patients...

Declared dead under a neocortical definition could be biologically maintained for years as opposed to a few hours or days, as in the case of whole brain death. Under the present Uniform Anatomical Gift Act, this raises the possibility that neocortically

dead bodies or parts could be donated and maintained for long-term research, as organ

banks, or for other purposes such as drug testing or manufacturing biological compounds.”

David Randolph Smith, US Lawyer, 1988

Organ transplantation in Japan: timeline

• 1958 An Act Concerning the Corneal Transplantation (from conventionally dead donors, with their prior consent, and that of surviving family members)

• 1979 An Act Concerning the Transplantation of Cornea and Kidneys • 1968 Wada case: first Japanese heart transplant, from donor in

‘irreversible coma’; surgeon accused of murder, but never prosecuted in court;

• 1983 Debate emerges when Japanese Ministry of Health and Welfare begins work to establish criteria for brain death;

• 1992 Prime Minster’s Committee on Brain Death and Transplantation concludes that brain death = human death, but that donor’s prior declaration is necessary for transplantation. Minority Opinion denies that brain death = human death’

• 1997 Japanese Organ Transplantation Law establishes requirement for ‘donor’s prior declaration’ and family consent prior to brain-death diagnosis and organ removal; no donations allowed from children under 15; IF NO DONOR CARD, THEN ‘DEATH’ OCCURS ONLY WHEN HEART STOPS BEATING: patient is regarded as ‘alive’ until that moment;

Table 1 “Is brain death equivalent to human death?” Yes No1987 Yomiuri Shimbun Newspaper 46% 28%1991 Mainichi Shimbun Newspaper 45% 23%1992 Asahi Shimbun Newspaper 47% 41%1997 Asahi Shimbun Newspaper 40% 48%1999 Asahi Shimbun Newspaper 52% 30%

Organ transplantation in Japan: timeline• 1999 Second Japanese heart transplant

performed; by 2001, 14 cases of heart transplantation.

• 2001 Japanese Organ Transplantation Law scheduled for reconsideration

• 2005 Japan Paediatric Society determines that it is too early to reconsider ban on transplants from brain-dead child donors

• February 16 2009, JPS establishes study panel on allowing child donors, largely in response to critique of Japanese ‘transplant tourism’ due to Japan’s organ shortage, and WHO call for countries to meet their own organ needs

Defining deathNorth America, Europe Japan

Brain-death (either non-function of cerebrum [UK] or of cerebrum and brain-stem [US]), cardio-pulmonary death;

Doctors choose definition of death (in consultation with patients/families);

Doctors also define the moment of death in individual cases; death is a biological phenomenon; limited role for families.

Cardio-pulmonary death, ‘clinical brain death’ (non-function of cerebrum and brain-stem), ‘Legal brain death’ ( as clinical, but apnea also required);

Individuals choose their definition of death;

Strong role of family: ‘death’ is a social phenomenon.

Medical profession moved quickly to define death as brain death; legal profession concurred

Medical profession slowed by scandal of first transplant, popular distrust; legal profession opposed ‘brain death’

Cultural acceptance of ‘gift of life’ rhetoric, even though no social relationship is possible between giver and recipient

‘Gift of life’ rhetoric culturally awkward due to general expectations of reciprocity in gift-giving, and focus on gift-giving as foundation of social relationships

Locating personhood in the body

• West: ‘Cogito ergo sum’ (I think therefore I am): personhood equates to rationality, abides in the mind/brain. Emphasis on attaining perfect health for the body, by whatever means necessary.

• Japan: personhood depends on tamashii (soul) in life abides in the hara (abdomen), in death, the kubi (neck). Emphasis on ‘gotai manzoku’ or bodily integrity without addition of foreign elements

Medical profession moved quickly to define death as brain death; legal profession concurred

Medical profession slowed by scandal of first transplant, popular distrust; legal profession opposed ‘brain death’

Cultural acceptance of ‘gift of life’ rhetoric

‘Gift of life’ rhetoric culturally awkward due to general expectations of reciprocity in gift-giving

‘beating heart cadaver’

‘neomort’

‘shiju-ku-nichi’ (period of 49 days required for soul to detach from body)

Responses to transplant technologies, cyborg possibilities

Questions for seminar

• Why is there such debate in the US about abortion, and so little about ‘brain death’?

• Why is there so much debate in Japan about ‘brain death’ and so little about abortion?

Note:In Week One of Term 3 We will meet in the Teaching Grid, 2nd

Floor of the Main Library.