Doornails and dodos are certainly dead, either because they were never alive or because they stopped breathing in the 17th century. But determining exactly when the rest of us shuffle off this mortal coil is not so easy, especially for doctors who want organs of certifiably dead people. An article in the Boston Globe highlights a little-known dispute in the profession about whether most donors are alive or not when their organs are removed. The universally accepted “dead donor rule” forbids the removal of essential organs from living donors. This reassures potential donors and the public that transplant surgeons are not just high-tech ghouls. People are normally deemed to be dead when their brain ceases to function. This is the state of so-called “brain death”. But, says a medical ethicist at Harvard Medical School, Dr Robert Truog, this definition crumbles upon closer examination. “It’s completely ethical to remove organs from patients we diagnose as brain dead,” he says. “It’s just ethical for reasons other than that we think they’re dead, because I don’t think they are.”

Truog’s critique of what it means to be dead is supported by other physicians. "Brain death is not true death,” says Dr Paul Byrne, who has been an outspoken critic of the brain death criteria for many years. “Brain death is a fiction concocted to get organs. After true death very few, if any, organs are suitable for transplantation. True death is the body without life, when disintegration sets in. It is more than just non-functioning, which brain death revolves around.”

And University of Wisconsin medical ethicist Dr Norman Fost points out that the brain, or parts of it, may still be functioning in “brain dead” people. For instance, many have a functioning hypothalmus, which regulates blood pressure and appetite. “We have been taking organs out of those patients by the thousands,” he says. “And they are not brain dead.”

Other doctors, however, assert not only that that brain death is an adequate criteria, but that there is nothing to talk about. A leading authority on the topic, Dr Eelco Wijdicks, of the Mayo Clinic, told the Globe that the concept is widely accepted by neurosurgeons and neurologist. “There is no controversy about brain death,” he says.

The older criteria for determining death was cardiac death, or when the heart stopped beating. This fell out of favour after brain death became widely accepted, because organs from people whose hearts had stopped beating were not as viable. However, with the growing shortage of organs, donation after cardiac death is being revisited. Patients with no apparent chance of recovery are removed from ventilators; their hearts eventually stops; and within two minutes their organs are being removed. But Fost finds this criterion just as unsatisfactory. He and other critics point out that countless people have been resuscitated after their hearts stopped for two minutes.

What is really under threat is the dead donor rule itself. Truog and Fost and other ethicists are by no means opposed to organ donation. Indeed, they want to expand the potential pool of donors to include people who are manifestly not dead, but will never become conventionally alive: people in a permanent vegetative state, people who consent to having their organs removed when they lose consciousness, anencephalic children, and so on. “Reconsidering the Dead Donor Rule: Is it Important that Organ Donors Be Dead?” was the unsettling headline over one of Dr Fost’s articles. Stay tuned for future developments as the organ donor shortage becomes more acute. ~ Boston Globe, Mar 9; Zenit, Mar 2