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

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Brain-dead medical morality in the non-western
world

• HI 269
• Week 20

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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

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Life, death the Romeo error
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Photo of c. 1890 Burial vaults, Popular Mechanics
Magazine, 1921 (wikimedia commons,
http//en.wikipedia.org/wiki/FilePremature_Burial
_Vault.JPG accessed 8/03/09)
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Life after breath Impact of the Iron Lung
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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

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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 1968721).
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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
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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
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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 Minsters Committee on Brain Death and
  Transplantation concludes that brain death
  human death, but that donors prior declaration
  is necessary for transplantation. Minority
  Opinion denies that brain death human death
• 1997 Japanese Organ Transplantation Law
  establishes requirement for donors 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

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Table 1 Is brain death equivalent to human
death?
Yes No 1987 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
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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
  Japans organ shortage, and WHO call for
  countries to meet their own organ needs

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Defining death
North 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
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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

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Responses to transplant technologies, cyborg
possibilities
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)


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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?

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NoteIn Week One of Term 3 We will meet in the
Teaching Grid, 2nd Floor of the Main Library.