Dead yet? Science, scaremongering and organ donation

In his new book, Catholic bioethicist Nicholas Tonti-Filippini attempts to portray the surgeons involved in organ donation as modern-day grave robbers. As described in a recent article in The Age, Professor Tonti-Filippini poses that some patients who are diagnosed as “brain dead” are not really dead…

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Tont-Filippini’s claims could arose fears in the community and prompt people to reject organ donation. Melvin Es

In his new book, Catholic bioethicist Nicholas Tonti-Filippini attempts to portray the surgeons involved in organ donation as modern-day grave robbers.

As described in a recent article in The Age, Professor Tonti-Filippini poses that some patients who are diagnosed as “brain dead” are not really dead because there is some mid-brain function. Further, he argues that brain blood flow testing should be performed to ensure these patients are not prematurely declared dead and inappropriately have their organs donated.

So what is brain death and how is it diagnosed?

According to the Australian and New Zealand Intensive Care Society, whole brain death is required for the legal determination of death in Australia and New Zealand. A patient must be declared dead by a physician in order for deceased organ donation to be permitted.

Brain death occurs following a severe brain injury associated with significant elevation of pressure in the skull (called intracranial pressure). As the brain swells, exposure to oxygen reduces and intracranial pressure increases. Eventually brain blood flow ceases and the entire brain, including the brainstem, permanently dies. There is no recovery from brain death.

Neither myself nor Tonti-Filippini are neurologists and it’s important to note that those clinicians are the genuine experts in the field and undertake ongoing research. In fact, the Quality Standards Subcommittee of the American Academy of Neurology updated its practice parameters for determining brain death in 2010.

The Academy also created a brochure which clearly explains the key features of brain death diagnosis to families:

  1. the person is in a permanent coma, and the cause of the coma is known;

  2. all brainstem reflexes have permanently stopped working; and

  3. breathing has permanently stopped.

If these three items are verified and there are no confounding factors (such as hypothermia) or situations that could mimic neurological death, doctors can diagnose irrecoverable brain death. If there is uncertainty, confounders, or mimicking conditions, then a diagnosis of brain death cannot be made and further testing, such as brain blood flow imaging, is performed.

Whole brain death is required for the legal determination of death. Surgeon image from shutterstock.com

It seems Tonti-Filippini doubts the certainty of the three diagnostic parameters and asks the public whether the current approach is acceptable. The problem with his method is that very few of us are neurologists and most lack the scientific preparation to analyse Tonti-Filippini’s doubts.

As a consequence, his fears have the potential to spread and affect the community’s views of organ donation, with families refusing to honour their loved one’s wish to be an organ donor, and people removing their name from the donor registry or simply refusing to register.

Research and academic debate are important features of medicine and are critical to ensure clinically and ethically appropriate practises. But Tonti-Filippini’s latest claims seem merely a lightening rod of emotive oration. Along the way, patients with end-stage organ failure potentially endure more suffering as their waiting time for an organ increases.

Now is the time for professional societies in the spheres of transplantation and neurology to weigh in. Now is also the time for adults to talk to their families about their wishes and values about organ donation.

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25 Comments sorted by

Comments on this article are now closed.

  1. Debra Joan Smith

    Account Executive

    This is the sadest article I could possibly read. With so many people in need and so many healthy organs going to rot in graves- what sort of love- especially Christian love is represented by this selfishness? People are fearful of donating anyway- who would want to falsely encourage such fear? I will fight it.

    I told my story on another article here once before but it bears repeating for all of our sick friends and neighbours around the world. I was in exactly the 'dangerous' position that is…

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    1. Katrina Bramstedt

      Associate Professor, Medical Ethics at Bond University

      In reply to Debra Joan Smith

      What you describe is the concept of donation referraling and how this is handled can vary signficantly from country to country. For example, in the USA, there is a regulation that requires ALL imminent deaths to be referred to the local organ procurement organization (no matter the age of the patient, the diagnosis, etc). In other countries, the judgment can be left to a physician to decide whether or not he/she will make a referral-- what if the doctor, himself, is not a supporter of organ donation/transplant? what if he/she is not well-informed about donor candidate criteria? what if he/she does not view it as a priority/too busy? Result: missed opportunities.

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    2. Debra Joan Smith

      Account Executive

      In reply to Katrina Bramstedt

      Thank you Katrina, I agree whole heartedly that the system is ALREADY biased against such a life affirming and hope filled choice and that is why I chose to share my story which is from another commonwealth country somewhat similar in many ways to this beautiful nation of Australia.
      So many people need organs that are left to disintegrate. I only wish to put some of the fear that is stirred up in this article to rest.

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    3. Brian Myerson

      Director of not for profit organisation

      In reply to Katrina Bramstedt

      Ah Katrina you write such sense thank you. And that is why it is essential to have a system ensuring that an experienced doctor monitors all patients in his/her hospital who are in the process of dying, independent of the treating physician.

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    4. Carol Daly

      Director

      In reply to Debra Joan Smith

      Thanks to Katrina for this article and I agree with Debra that it is the saddest situation when it has to be written at all.
      Again a church philosopher (who calls himself an ethicist when he is really a theologian) wants to interfere in the very well researched and applied scientific knowledge of the expert medical profession interfering with a person's rights to be treated in accordance with best practice.
      Best practice includes saving the lives of those in need of organ donation with donated organs.
      Letting good organs rot or be cremated when people could agree to donate them is not about 'love one another as the Father has loved you'.
      Good on you Debra for your recovery and for your signed medical directions.

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    5. Katrina Bramstedt

      Associate Professor, Medical Ethics at Bond University

      In reply to Brian Myerson

      With regard to best practices, as an example, NATCO, an international professional society with links in Australia, the UK, Canada and Japan (for example) endorses the position of the Joint Commission (a hospital accreditation body) that all deaths as well as imminent deaths (e.g., early notification of patients with a GCS of </= 5) be referred. Best practice systems involved in the treatment, referral and consent processes also aim to prevent, reduce, and disclose conflicts of interest-- prevention…

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  2. Rosemary Doolan

    Retired RN, Perioperative Nurse Specialist

    My comment is in relation to the photo of a surgeon contained within this article. There is no way that you put on a mask AFTER you have scrubbed and donned your sterile surgical gloves. The mask is not sterile and is put on BEFORE you scrub. If the photo you have chosen is faulty, then I suspect that some of the detail in the aricle is likewise.

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    1. Katrina Bramstedt

      Associate Professor, Medical Ethics at Bond University

      In reply to Rosemary Doolan

      I'm not aware of the procedure for selecting photos for these articles but possibly the Editor felt this was the best royalty-free match in spite of its technical failing? I cannot speak for the Editor/Publisher. With regard to "detail in the article", readers can refer to the embedded links for follow up/references.

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    2. Alan Udell

      Actuary

      In reply to Rosemary Doolan

      Alternatively the surgeon could be taking the mask OFF AFTER the operation. So then you would not be denigrating the article?

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    3. Fron Jackson-Webb

      Section Editor at The Conversation

      In reply to Rosemary Doolan

      Hi Rosemary. I'm the editor who worked on this article; I selected the image. Thanks for pointing out its flaws, but please don't let it detract from the content of A/Prof Bramstedt's article.

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    4. Rosemary Doolan

      Retired RN, Perioperative Nurse Specialist

      In reply to Alan Udell

      Allen...your gloves are bloodied following surgery...the last thing you remove is your mask as you are still in the sterile area of the operationg room...not sure anyone would want to put bloodied hands near their face at any time...gloves are the first thing that is removed, followed by gown then mask once you are away from the sterile area....and my personal opinion on organ donation after having worked with a procurement and transplant team...I don't like it...blood, kidneys yes...anything elses no, but people are free to choose...my son is a donor and I respect that, but for me, no.

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    5. Michael Hay

      retired

      In reply to Katrina Bramstedt

      I do hope that when I die, I shall be dead and whatever parts of my body are useful to somebody else shall be used for their benefit. I wish Tonti-Filippini would keep his ethical dilemmas to himself and allow the rest of us to live (and die) in peace, without having to put up with his foolish pursuits.

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    6. Helayne Short

      irrelevant

      In reply to Michael Hay

      For the record Michael, have you actually read Tonti-Filipipini's book?
      Helayne

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  3. Russell Walton

    Russell Walton is a Friend of The Conversation.

    Retired

    Oh jeeeez, not another health scare campaign promoted by an individual with no medical qualifications whatsoever--"to each his own trade". It will probable get plenty of traction in the MSM and on the Net, unfortunately.

    Does the Catholic church have an ideological problem with organ donation?

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    1. Katrina Bramstedt

      Associate Professor, Medical Ethics at Bond University

      In reply to Russell Walton

      I don't want to make any boradsweeping generallizations about the Catholic Church or the Vatican; however, I will say that some of my most intellectually and philosophically complex transplant ethics consults have involved hospitals belonging to Catholic healthcare systems. For some guidance, see items 30 & 63-65 in the following link: http://www.usccb.org/issues-and-action/human-life-and-dignity/health-care/upload/Ethical-Religious-Directives-Catholic-Health-Care-Services-fifth-edition-2009.pdf

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    2. Sue Ieraci

      Public hospital clinician

      In reply to Russell Walton

      The relevant extract from that document (referenced by Katrina) says this:

      "62. The determination of death should be made by the physician or competent medical authority in accordance with responsible and commonly accepted scientific criteria.
      63. Catholic health care institutions should encourage and provide the means whereby those who wish to do so may arrange for the donation of their organs and bodily tissue, for ethically legitimate purposes, so that they may be used for donation and research…

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  4. Michael Leonard Furtado

    Dr at University of Queensland

    Professor Tonti-Fillipini is a member of the Australian Health Ethics Committee of the National Health and Medical Research Council and chair of the sub-committees on the Unresponsive State and Comercialization of Human Tissue. His research is principally concerned with ensuring that the chronically ill shouldn't feel pressured to relinquish their fragile hold on life. Even though there is considerable pressure by the pro-euthanasia lobby to overturn this, I am not aware that Nicholas's position…

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    1. Katrina Bramstedt

      Associate Professor, Medical Ethics at Bond University

      In reply to Michael Leonard Furtado

      For a biosketch of Professor Tonti-Fillipini see http://www.herdsa.org.au/?page_id=1331.

      Also, religious values can indeed inform a person's beliefs about life, healthcare, and death (as well as other issues) but I don't see anti-Catholic bias here. Readers should be aware that there is great controversy among Catholic hospitals, for example, with regard to organ donation in situations involving brain death v DCD. As I mentioned in an earlier comment, for more info on organ donation and Catholic hospitals see http://www.usccb.org/issues-and-action/human-life-and-dignity/health-care/upload/Ethical-Religious-Directives-Catholic-Health-Care-Services-fifth-edition-2009.pdf

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  5. Cat Mack

    logged in via Facebook

    Oh alright I will act as the dissenter here. But a few things first. 1. I'm not (invariably) against the use of brain death as a criteria for death. 2. I am not against organ donations as such. 3. I am an atheist.

    Even so, I think this is a very odd and defensive little article.
    There are in fact some quite legitimate questions to ask about our use of central brain cessation (brain death) to diagnose death and I am greatly surprised that an ethicist should put the view that “we” are unable…

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    1. Katrina Bramstedt

      Associate Professor, Medical Ethics at Bond University

      In reply to Cat Mack

      As indicated to another reader, my intent is to not exclude the general public from this dicussion, or to infer that they 'lack intellegince' but rather to bring the neurolgists into the discussion because the topic at hand cannot be disconnected from their scope of practice or their duty of care. Topics like this are a lot to unload on the lay public and thus the input of neurologists is not only helpful but obligatory.

      And certainly, there are many important issues to tackle in transplant ethics (in addition to death declaration, pt referrals): organ tourism, organ selling, ageism, listing criteria, extended criteria organs, and on and on...

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  6. Helayne Short

    irrelevant

    I have not read the book but query Katrina Bramstets' own "emotive oration", see below exert from her article for one example.

    "But Tonti-Filippini’s latest claims seem merely a lightening rod of emotive oration. Along the way, patients with end-stage organ failure potentially endure more suffering as their waiting time for an organ increases."

    'On the way' to what Katrina? People discussing the issues raised by this bloke? Or people investigating (the average person is not an idiot as you so arrogantly assume) doctors claims their loved ones are in fact 'brain dead'? This is a serious issue that needs serious discussion by the whole community, not just medico's. The community must maintain control of this important issue, and not leave it up to the medical fraternity to tell us what to think and why. Cat Mack raises good points.

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    1. Katrina Bramstedt

      Associate Professor, Medical Ethics at Bond University

      In reply to Helayne Short

      Apologies for not being clear. My intent is to not exclude the general public from this dicussion, or to infer that they are "idiots" (your word not mine) but rather to bring the neurolgists into the discussion because the topic at hand cannot be disconnected from their scope of practice or their duty of care.

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  7. Sue Ieraci

    Public hospital clinician

    Perhaps one of the things missing from this discussion is the distinction between any brainstem function at all as opposed to brainstem function that is capable of sustaining life.

    People whose brainstem reflexes have stopped working (and are therefore being considered for donation) are kept breathing by ventilators - and their circulation is generally kept going by drugs and fluids. Independent of the ventilator, these people can;t breathe or sustain their own life.

    Outside the context of donation, the families of people who are declared clinically brain-dead enter into end-of-life discussions. If the condition is not recoverable, then at some stage mechanical support will cease.

    On the other hand, people being considered for donation will be kept artificially "alive" to keep the organs oxygenated and perfused.

    Does Tonti-Fillipini distinguish a brain stem with some blood flowing through it from one that can sustain life?

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