We report here the second part of the interview with Doyen Nguyen, in which she explains, more specifically of CCCD and its anthropological rationale.

Are there protocols regarding non-beating heart transplantations?

A more correct name for non-beating heart donation is Controlled Cardiac-Circulatory Death (CCCD). The term CCCD indicates the inherent and inseparable connection between the heart and blood circulation, i.e., the cardio-circulatory system works as one unit because the function of the heart requires circulating blood, but at the same time, without the pumping function of the heart, there would be no blood circulating. The term CCCD also indicates that in this protocol, the moment of death is determined with precision under controlled condition [15].

Now, as we all know by common sense, death (understood in the sense of natural death) comes uninvited, which means that we cannot know when it takes place exactly. Scientifically speaking, the exact moment of death cannot be determined because death occurs instantaneously (death is an instantaneous event). Metaphysically speaking, death is the separation of the soul (which is immaterial) from the body. As such, it is an event of which no human technique or device can predict or determine the exact moment. Ironically, a key feature of CCCD is that it establishes the exact moment of death!

Since the CCCD-paradigm coordinates the timing of withdrawing the ventilator with the readiness of the organ – procurement team to remove organs from the CCCD donor, all the different CCCD protocols basically follows the pattern described below [16]:

1. The potential donor is a severely brain-injured patient but not brain dead, who is expected to die promptly (usually within about 30-60 minutes) once life support is removed;
2. CCCD requires two separate informed consents: first, the consent for the ‘do not resuscitate’ (DNR) order which permits the removal of life support, followed by the consent for organ donation;
3. The patient is taken to the operating room where he/she is rapidly weaned off life support. This invariably requires the administration of narcotics and sedatives to relieve or prevent discomfort;
4. As part of the ante-mortem preparation for the procurement operation, the patient is heparinized, his femoral artery cannulated, and his skin prepped and draped;
5. Following a brief observation period (the “death watch” or the “no touch” period) after onset of the cardiorespiratory arrest, the patient is declared dead. In the Pittsburgh protocol, death is declared after two minutes of (a) no pulse pressure recorded by arterial catheter, or flat electrocardiogram, (b) no heart sounds, (c) apnea, and (d) unresponsiveness. The duration of the death watch varies from 2 to 5 minutes depending on the particular protocol. In the European Maastricht protocol, the “death watch” period lasts 10 minutes: “in these 10 minutes of no circulation, the brain will be dead”. The result would be a “situation equivalent to brain death” [17]. Because of the long duration of the “death watch,” only the kidneys can be harvested because they are more resistant to ischemia than other vital organs (e.g., heart, lungs, liver and pancreas)
6. Organ procurement proceeds immediately at the declaration of death;
7. Some CCCD protocols include a post-mortem procedure (Michigan protocol): veno-arterial extracorporeal membrane oxygenation (ECMO) after cardiac arrest to restore the flow of warm oxygenated blood during the interval between death and organ procurement.

Note: In about 25% of cases, the potential CCCD donor still lives beyond 1 hour after the removal of life support. Procurement surgery is cancelled because the ischemia during the dying process has been too prolonged, thus rendering the organs unusable.

Once we clarified what BD is, which is, in brief, the underlying anthropological idea and metaphysics? Which main incoherence can be found?

As mentioned above, the CCCD paradigm is built on the BD paradigm, based on the presumption (a false presumption, however) that the “no touch” of 2-5 minutes (or 10 minutes in the Maastricht protocol) duration is sufficient to created a situation similar to BD. Hence, it can be said the both CCCD and BD are undergirded by the same philosophical thesis which claims that the brain is the supreme master organ responsible for the integration of the body (i.e., the integration of the human organism) and without which the human being dies (disintegrates. Such a thesis sets the brain over and against the body, in a way analogous of the Cartesian dualism in which the mind is set over and against the body. Now, the absurdity of such a thesis can be demonstrated in more than one way. Here I will just mention three.

First, let us start from the empirical evidence: how is possible that the brain is the master central integrator of the body when, in the embryo, the neural groove (i.e., the earliest evidence of the formation of the central nervous system) does not appear until the end of the 4th week of pregnancy? The embryo is already an integrated, living and developing organism well before the appearance of the neural groove. Moreover, the development of the brain occurs well after that of the heart and blood vessels. Pro-life yet pro-BD Catholics (e.g. M. Condic and M. Moschella) merely asserts, without any explanation, that in the post-natal stage of human life the brain is the master organ. How, when and why the brain just suddenly becomes the master organ in the post natal stage of life?

Second, let us examine the thesis simply on the basis of efficient causality. Classical philosophy speaks of four causes: material, efficient, formal, and final cause. Modern science, with its mechanistic thinking is interested only in the material and efficient cause. On the basis of efficient causality alone, the brain cannot be the master integrator of the human organism for the following simple reason:how does the brain itself remain integrated? No material entity can be its own cause of integration. Hence there must be another material entity to integrate the brain, in which case that entity takes precedence as the central integrator; but then it too in turn cannot account for its integration. This then set up an infinite regress [18]

Third is the axiomatic principle that an organic whole (a living whole) is ontologically prior to its parts and is greater than the sum of its parts. This axiom is foundational in both classical metaphysics and holistic contemporary biophilosophy. The corollary to this axiom is that no part can account for itself, let alone for the whole. In our context, the whole is the human being. The heart, the brain, the liver, the kidney, etc. are parts. It has been claimed that the brain is the most noble organ because it is the material basis for cognitive function. Nevertheless, however most noble it might be, the brain is just an organ just like any other organ in the body. As such it cannot account for itself, i.e., it cannot account for its integration, let alone for the integration of the whole human organism.

So then, you may ask, what is the master integrator of the human organism? In contemporary biophilosophy we speak of “that which integrates the body.” In classical metaphysics, the same thing is referred to as “that which informs the body” or “that which makes the body what it is.” But “that which makes the body what it is” is also that which gives esse (existence) to the organism. It is then none other than the principle of life which we call the soul. In short, the soul is the integrator of the body.

A message you would like to address to our readers …

First, a practical message: the only valid organ donation is living organ donation, in which it is possible to donate a kidney or a lobe of the liver. We speak of organ donation as a noble act of the gift of self. A gift, understood in its fullest sense, establishes a connection between the person who gives and the one who receives. Hence, to make a gift of self necessarily leads to a bond between the donor and the recipient. Why do we then insist so much on the anonymity of donors? To whom would the recipients be grateful then? How enduring would our sense of gratitude be if we do not even know the person who did the gift of him or herself in organ donation? Anonymity leads to dehumanization of the donors. It becomes then convenient to view a patient in irreversible coma as a bag of transplantable organs, instead of recognizing that he/she is living (even though dying) person. So, now that you know the ugly truth about BD and CCCD, you should know what to do. Morally speaking, you must take steps not to be “an organ donor after death” precisely because in the context of organ donation, the word “death” does not indicate true death, but rather BD, or CCCD, or some other newer definition of death.

Second, a spiritual message: what happens then if you were to be a recipient? You should have the spiritual strength and moral courage of not accepting to receive organs obtained by means of BD, CCCD, or euthanasia. Note that in fact, BD and CCCD are just veiled forms of euthanasia, designed primarily for the sake of obtaining organs.

References:

[15] D. Nguyen, The New Definitions of Death for Organ Donation: A Multidisciplinary Analysis from the Perspective of Christian Ethics(Bern: Peter Lang, 2018), p.21-26, 115-135.

[16] D. Nguyen, The New Definitions of Death for Organ Donation: A Multidisciplinary Analysis from the Perspective of Christian Ethics(Bern: Peter Lang, 2018), p.21-22.

[17] G. Kootstra, “Ethical Questions in Non-Heart-Beating Donorship.” Transplantation Proceedings 28, no. 6 (1996).

[18] D. Nguyen, “Why the Thomistic Defense of “Brain Death” is not Thomistic: an Analysis from the Perspectives of Classical Philosophy and Contemporary Biophilosophy,” The Thomist82 (2018).

Interview of Fabio Fuiano

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