Transplantation Ethics

Second Edition

Robert M. Veatch, Lainie F. Ross

• Publisher: Georgetown University Press
• Year: 2015
• Print ISBN: 9781626161672, 9781626161689
• eBook ISBN: 9781626161696
• Edition: 2
• Topic: Medicine
• Subtopic: Ethics in Medicine

Although the history of organ transplant has its roots in ancient Christian mythology, it is only in the past fifty years that body parts from a dead person have successfully been procured and transplanted into a living person. After fourteen years, the three main issues that Robert Veatch first outlined in his seminal study Transplantation Ethics still remain: deciding when human beings are dead; deciding when it is ethical to procure organs; and deciding how to allocate organs, once procured.

However, much has changed. Enormous strides have been made in immunosuppression. Alternatives to the donation model are debated much more openly—living donors are used more widely and hand and face transplants have become more common, raising issues of personal identity. In this second edition of Transplantation Ethics, coauthored by Lainie F. Ross, transplant professionals and advocates will find a comprehensive update of this critical work on transplantation policies.

Chapter 1

Religious and Cultural Perspectives

Although fantasies about replacing body parts date from ancient times, the modern bioethical debate over organ transplants does not go back much further than the first kidney transplant in 1954—only a moment in time in the history of the world’s religions and cultures. The current generation of controversy, however, is even more recent. It can be dated from December 3, 1967, when a South African physician, Christiaan Bernard, transplanted the first human heart into the chest of Louis Washkansky. It is thus necessarily difficult to determine what the great religious and cultural traditions might have thought about such a project.

We can imagine someone seeing such an enterprise as “tampering” with God’s creation. Conversely, Judeo-Christianity, one of the world’s great religious traditions, has long taught that the human was created with the command to have dominion over the Earth and subdue it—to use the God-given faculties of reason and observation to overcome illness and heal the afflicted. Although some sectarian religions might see all of modern medical science as reflecting a lack of adequate faith in divine power, the mainstream Western religious traditions have supported the use of medical science. Their members have run hospitals, trained physicians and nurses, and contributed countless sums attempting to overcome disease.

Before pursuing the more specific issues of the ethics of transplants, however, it is helpful to look at the positions of the major religious and cultural traditions to see how they incorporate this very new issue into their ancient ethical frameworks. The contemporary bioethical debate over organ transplantation contains two issues that can be considered preliminary and two issues that are central or core. The ethics of the definition of death, which is the focus of part I of this volume, and the potential controversy over intervening in a dead body for the removal of cadaver organs can be thought of as preliminary. The justification for procuring organs, which is the subject of part II, and the distribution of organs once procured, which are explored in part III, are central.

Defining Death and Desecrating the Corpse: Two Preliminary Issues

We first consider the two preliminary issues: defining death and removing organs from dead bodies. Both are addressed, at least indirectly, by many of the world’s religions.

Defining Death

All the major religious traditions reveal some differences of opinion over a shift to the use of a brain-oriented definition of death, a shift that is important if organ procurement is to be facilitated. Let us briefly consider their views.

Judaism

Within Judaism, there has been considerable resistance to shifting to a brain-oriented definition of death. Rabbi David Bleich, a philosopher at Yeshiva University, for example, opposes any shift, saying that “the patient cannot be pronounced dead other than upon the irreversible cessation of both cardiac and respiratory activity.”¹ This interpretation was confirmed recently by the United Kingdom’s chief rabbi, Jonathan Sacks, who issued an edict indicating that Judaism can only accept the traditional halachic definition based on cardiorespiratory failure.² Conversely, other rabbis from the Conservative and Reformed traditions have endorsed the use of brain criteria for death pronouncements.³ The Orthodox Rabbinical Council of America takes no stand on whether brain-based death pronouncement conforms to halachic teaching.⁴

Roman Catholicism

Among Catholics, Pope Pius XII opened the door for a shift in the definition of death in 1957, saying, “It remains for the doctor, and especially the anesthesiologist, to give a clear and precise definition of death and the moment of death of a patient who passes away in a state of unconsciousness.”⁵ In the United States, the most recent statement of the Conference of Catholic Bishops continues to imply that “commonly accepted scientific criteria” provide a basis for determining death.⁶ There have never been any principled theological objections to a brain-oriented definition of death among Catholics, although occasionally conservative Catholics, often those most militantly associated with right-to-life positions, have expressed the fear that endorsing the view that an individual is dead when the brain is dead might indirectly lessen respect for those who are still living.⁷ Recently, a few Catholic commentators have criticized brain-based death pronouncements, but a September 2006 meeting convened by the Pontifical Academy of Sciences reaffirmed the papal position that a human dies when brain function is lost irreversibly.⁸

Protestantism and Eastern Orthodoxy

Protestant theologians and Protestant groups, when they have spoken on the subject, have almost uniformly favored some brain-oriented definition of death, whether they represent more conservative (Paul Ramsey) or liberal (Joseph Fletcher) perspectives.⁹ Major Protestant communions support its use, including Anglicans, Lutherans, Methodists, and the Reformed traditions.¹⁰ The same can be said for Eastern Orthodox groups.¹¹

Thus, though there is some concern about the use of a brain-oriented definition of death, at least some responsible members of all major Judeo-Christian religious traditions accept it theologically and find it appropriate as a basis for procuring organs from deceased donors. Most have not pursued the more recent distinction, made in part I of this book, between whole-brain and higher-brain views, although some who have worked in both the Catholic and Protestant communities have moved on to endorse the higher-brain view. Almost all in these traditions also accept organ procurement from people pronounced dead by traditional circulatory criteria.

Other Major Religions

Most of the other major religions of the world also have members who have come to accept death pronouncement based on brain criteria. Let use briefly examine each one.

ISLAM

The 1981 Islamic Code of Medical Ethics of the International Organization of Islamic Medicine is vague on the subject of the definition of death. In language reminiscent of Pius XII, it said, “To declare a person dead is a grave responsibility that ultimately rests with the Doctor.”¹² It says nothing against the use of brain criteria for death pronouncement, but does not explicitly endorse them either. Initially, there were reservations among Muslims about death defined as lack of brain activity rather than the conventional definition of respiratory and circulatory arrest. These issues were discussed at a seminar titled “Human Life: Its Inception and Its End as Viewed by Islam.”¹³ The report of this meeting concluded that the Quran does not define death. The participants came to the conclusion that when the area of the brain responsible for vital body functions is lifeless, the patient can be said to have died. This they identified with the brain stem.¹⁴ They concluded that while the brain stem is still alive, all efforts must be made to revive the person. If the brain stem is dead, even when signs of activity are still visible in the bodily organs, and if there is no hope of reviving the patient, then the patient is “considered to have withdrawn from life,” and behaviors associated with the dead—including procuring of organs—are permitted.¹⁵ A similar conclusion was reached at the Third International Conference of Islamic Jurists meeting in Amman in October 1986, where they endorsed the view that a person may be declared dead either based on heart criteria or if there is “complete stoppage of all the vital functions of the brain, and the doctors decide it is irreversible, and the brain has started to degenerate.”¹⁶ Some Islamic countries, such as Turkey, have an explicit law defining death in terms of irreversible loss of brain function.¹⁷ Iran accepted this view by law in 2000, and its Cabinet Council established bylaws governing brain-based death pronouncement in 2002.¹⁸

HINDUISM

Traditionally, Hindu texts associated death with respiratory failure. However, a physician, Prakash Desai, who is a specialist in Indian medical ethics, claims to see a basis for support of brain death in the notion from folklore that at death the prana (breath) escapes from the brain.¹⁹ Suffice it to say that there appears to be no formal resistance to death pronouncement based on brain function criteria in Hinduism.

CONFUCIANISM/TAOISM

In China traditional religious and cultural systems of thought are still influential, although it is often hard to draw direct links between traditional views and contemporary biomedical practices. Because “brain death” was not explicitly recognized in ancient times and traditional Chinese religious thought has not received much attention in contemporary Marxist China until very recently, it is hard to know exactly what the major Chinese systems of belief and value would think about it. There is nothing explicit to which one could point to identify resistance to brain-based concepts of death in either Confucian or Taoist thought, but there are reports that there is a “lack of widespread acceptance of ‘brain death’ criteria in China.”²⁰

BUDDHISM AND SHINTOISM

In addition to the traditions already mentioned, India and China—as well as many other Asian countries—are influenced by Buddhism. Buddhism is decidedly ambivalent about organ transplantation, and especially about efforts to redefine death that are linked to facilitating transplants. As with the other major religious traditions, Buddhism comes in many different varieties, and its expression varies from one country and group to the next.

Japan is particularly well known for its resistance to brain-oriented definitions of death, and this resistance is often attributed either to Buddhist influences or to the indigenous Japanese belief system that Westerners call Shintoism. Buddhism does not directly oppose brain-oriented definitions of death, but it has sometimes suggested skepticism. A 1990 report from the Japanese Association of Indian and Buddhist Studies could only state the opinion that “Buddhists should resolve the issue of brain death and organ transplantation,” expressing the confusion found in Pope Pius XII and other Western thinkers that this is a question for physicians to resolve. It said in somewhat nonsyntactic English, “We Buddhists ask the medical world to make a consensus among medical doctors.”²¹

Some Buddhist scholars find a brain-based concept of death compatible with their traditional concept of death. The Buddhist co...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Dedication
• Contents
• List of Illustrations
• Preface
• 1 Religious and Cultural Perspectives
• 2 An Ethical Framework: General Theories of Ethics
• Part I: Defining Death
• Part II: Procuring Organs
• Part III: Allocating Organs
• Index