We report here an interview with Doyen Nguyen, M.D., S.T.D., an academic hematologist and moral theologian. In this interview, we will discuss about “brain death” and “controlled cardiac-circulatory death,” from both the scientific and philosophical perspectives. The purpose of this interview is to help the public to be aware of the dark side of organ donation-transplantation.

Hi, Doctor Nguyen, it’s a pleasure for us to have you here!

Let’s start with some reference coordinates, in order to achieve a better understanding of the principles constituting brain death criteria. First of all, in synthesis, are there any scientific evidence or empirical data that support brain death and were used to validate diagnosis criteria? Are there evidence in disagreement?

In 1968, the Harvard Committee introduced the BD protocol by defining “irreversible coma as a new definition of death.” [1]. In other words, BD is actually irreversible coma.

The Harvard BD protocol consists of the following criteria:

• Coma and complete unresponsiveness;
• Absent brainstem reflexes;
• Absent respiratory drive, i.e., the patient fails the apnea test;
• Flat electroencephalogram (EEG).

The above-mentioned criteria are the clinical tests performed at the bedside. It is therefore best to refer to them as “clinical test-criteria”.

Was any of the above criteria validated prior to their introduction? Not at all. The Harvard report contains no scientific reference regarding these criteria. Put simply, these criteria were put forth by the Harvard Committee, and they were subsequently adopted as if they came down in Two Tablets (as if they were infallible divine teaching).

NB: By complete unresponsiveness, it is meant that the comatose patient demonstrates no response, not even to the most painful stimuli. There is no reflexes of the limbs (e.g., plantar reflex) either. Complete unresponsiveness implies that the whole nervous system is silent.

Since the early 1970’s, testing for EEG has become optional however. This came when the 1971 Minnesota study reported that some BD patients demonstrated brain electrical activity on the EEG. The authors of the Minnesota study simply declared that such activity was insignificant and that there was no need for EEG testing [2]

Once the patient fulfills the bedside clinical test-criteria of BD, then he/she is declared dead even though the heart is still beating, the blood still flowing, the skin still warm and pink, etc. If the BD individual is young (e.g., less than 60 years old) and healthy prior to the severe brain injury which led to the BD diagnosis (and therefore, the declaration of death), the patient can then be sent to surgery for the removal of his/her organs.

During the decades following the introduction of the Harvard BD criteria, it came to light that a significant number of patients who fulfilled the clinical test-criteria of BD still retained several brain functions including: (i) brainstem evoked potentials, (ii) detectable brain electrical activity on EEG, and (iii) persistent secretion antidiuretic hormone (ADH) by the posterior pituitary-hypothalamus axis. [3]

NB: Because of its critical role in fluid-electrolyte homeostasis, ADH is responsible for maintaining the human body in cardiovascular hemodynamic stability. In other words, the absence of diabetes insipidus and the presence of normal blood pressure in a BD patient means that ADH secretion is present.

Moreover, it also came to light that many brain-dead (BD) patients demonstrated “dramatic increase in blood pressure and heart rate,” “sweating and lacrimation” and contraction of abdominal muscles when they were being cut open for the removal of their organs [4][5][6].

Last but not least, it came to light that many BD patients manifested a wide range of tendon reflexes (e.g., plantar withdrawal reflex) and spontaneous movements (e.g., periodic leg movements similar to those occurring during sleep, respiratory-like movements). The most dramatic of such reflexes and movements is the Lazarus sign, which consists of “a complex sequence of movements characterized by bilateral arm flexion, shoulder adduction, and hand raising to the chest/neck” [7][8][9][10].

As a result of the above manifestations observed in BD patients, the original Harvard BD protocol got updated in 1995 by the American Academy of Neurology (AAN). According to the AAN guidelines, “the three cardinal findings in BD are coma or unresponsiveness, absence of brainstem reflexes and apnea.” At the same time, however, the AAN guidelines also declare that the presence of autonomic and motor responses, as well as spontaneous movements of the limbs do not invalidate a diagnosis of BD; likewise, the presence of persistent ADH secretion is compatible with a diagnosis of BD [11].

Now, let us just ask ourselves a few common sense questions: (i) can a dead body (i.e., a cadaver) move? Human beings belong to the category of warm-blooded mammals. The biological signs of death in humans are therefore no different from those observed when our pet dog or pet cat dies. After a dog dies, does it move? When you cut into a dead dog, does it respond with dramatic increase in heart rate and increase in blood pressure? The common sense answers to these simple questions bring you face to face with the factual evidence which falsifies the BD paradigm. In other words, the Harvard Committee defined irreversible coma as a new definition of death.

But does changing the definitions of a words or concept change the phenomenon indicated by that word or concept? Certainly not. Biological phenomena are realities which exist outside our mind. As such they are mind-independent, they are what they are irrespective of what we think or say about them. Truth requires that our words and concepts correspond to the realities outside our mind (Veritas est adaequatio rei et intellectus). In short, you can define irreversible coma (word or concept) to be a new definition of death (word or concept), but irreversible coma (the phenomenon) remains what it is, and is completely distinct from death (the phenomenon). A person in irreversible coma is someone who is still alive, even though he/she may be dying and very close to death. Only a person who is still alive can have reflexes or spontaneous movements of the limbs. Only a person who is still alive can secrete ADH. Only such a person can manifest increased blood pressure and increased heart rate in response to surgical incision at the time of the removal of his/her organs.

Moreover, there have been well documented cases of “chronic BD” survivors, e.g., the recent and well-known case of Jahi McMath. These were BD patients who, for one reason or another, were not subjected to organ removal, and who continue to live with the support of a ventilator, feeding tube, and some basic nursing care. In the case of pediatric patients with BD, their bodies continued to grow proportionately and undergo pubertal changes [12].

Now, once again, let us ask some common sense questions: have you ever seen a dead body which does not disintegrate and putrefy, but which continues to grow proportionately instead? We have seen that by divine intervention, some saints have incorruptible bodies. But they do not grow, if anything, they may even shrink in size. For a human body to grow and/or enter puberty means that the body still has ongoing metabolic activity. Metabolic activity is a multilevel complex process ranging from the molecular level to the macroscopic level, and from the assimilation of oxygen and nutrients to the excretion of carbon dioxide and waste [13].

Metabolic activity is immanent and constitutive of every living body. “Constitutive” means that metabolic activity cannot ever be substituted by any man-made technological device. The fact that your skin is warm and pink, and your body temperature remains constant is a clear indication that there is ongoing metabolic activity in your body, which then indicates that you are still alive.

Can you describe some protocols used to diagnose brain death and proceed with organs transplantation?

For your understanding there is a “salad” of terminologies, which all mean the same: “the neurological criterion for the determination of death”, the “brain-based criterion for the determination of death”, the “BD criterion”. Now, because the BD criterion consists of several clinical test-criteria, it gets very confusing between the words “criterion” and “criteria,” I use the word “BD protocol”, or “BD standard”, or “BD paradigm”. The BD protocol for organ transplantation comes down to this:

(i)  Establish the diagnosis of BD on the basis of the clinical test-criteria as described above. Some countries require EEG (e.g., France), other countries do not (e.g., USA). Some countries may also require testing for cerebral blood flow (CBF) testing. Note, however, that even if EEG and CBF testing are performed, the lack of brain electrical activity and of CBF does not necessarily indicate BD. The basic principle is logic: to say that the lack of the evidence of X means the lack of X is to commit a logical fallacy. There are other reasons why X, although it is present, is not evident. In the case of medical testing, it has to do with the sensitivity of the test. None of the tests, whether the clinical test-criteria at the bedside (including the apnea test) or CBF testing by various techniques, has been validated.

(ii)  Once the patient is declared dead according to the BD standard, then he/she can be sent for organ removal (i.e., organ harvesting). In some countries, this step requires informed consent, e.g. as indicated on the driver’s license of the BD donor. In other countries, e.g. in Austria, organ removal is automatic unless the person, prior to the BD event, had specifically indicated that he/she does not want to be a donor. In legal terms, it is the difference between the opt-in policy which requires informed consent, and the opt-out policy which is based on presumed [14].

References:

[1] Ad Hoc Committee of the Harvard Medical School, “A Definition of Irreversible Coma,” Journal of the American Medical Association 205, no. 6 (1968).

[2] A. Mohandas and S. N. Chou, “Brain Death: A Clinical and Pathological Study,” Journal of Neurosurgery35, no. 2 (1971).

[3] A. Halevy and B. Brody, “Brain Death: Reconciling Definitions, Criteria, and Tests,” Annals of Internal Medicine 119, no. 6 (1993).

[4] R. C. Wetzel et al., “Hemodynamic Responses in Brain Dead Organ Donor Patients,” Anesthesia and Analgesia64, no. 2 (1985).

[5] F. Conci et al., “Viscero-Somatic and Viscero-Visceral Reflexes in Brain Death,” Journal of Neurology, Neurosurgery & Psychiatry49, no. 6 (1986).

[6] R. D. Fitzgerald et al., “Cardiovascular and Catecholamine Response to Surgery in Brain-Dead Organ Donors,” Anaesthesia50, no. 5 (1995).

[7] Leslie P. Ivan, “Spinal Reflexes in Cerebral Death,” Neurology23, no. 6 (1973).

[8] A. H. Ropper, “Unusual Spontaneous Movements in Brain-Dead Patients,” Neurology 34, no. 8 (1984).

[9] L. Heytens et al., “Lazarus Sign and Extensor Posturing in a Brain-Dead Patient,” Journal of Neurosurgery71, no. 3 (1989).

[10] G. Saposnik et al., “Spontaneous and Reflex Movements in 107 Patients with Brain Death,” The American Journal of Medicine118, no. 3 (2005).

[11] E. F. M. Wijdicks, “Determining Brain Death in Adults,” Neurology 45, no. 5 (1995).

[12] D. A. Shewmon, “Chronic ‘Brain Death’: Meta-Analysis and Conceptual Consequences,” Neurology51, no. 6 (1998).

[13] D. Nguyen, The New Definitions of Death for Organ Donation: A Multidisciplinary Analysis from the Perspective of Christian Ethics(Bern: Peter Lang, 2018), p. 409-416.

[14] D. Nguyen, “’Brain Death,’ Organ Donation and Presumed Consent. Consent Cannot Be Presumed because ‘Brain Death’ is not True Death,” AEMAET8, no. 1 (2019).

To be continued …

Interview of Fabio Fuiano

Pubblicato da uniperlavita2

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