Organ Transplants, ‘Brain Death,’ and Church Teaching

Responding to my recent On the News post about organ transplants, reader James Anderson posed a question that requires more than just a quick answer:

I thought that I recently read where the Church said that determining when a person is dead falls under the purview of the medical community, not theologians. Unfortunately I can’t find that article. Please comment on this. 

It was Pope Pius XII who said that theologians must defer to doctors “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.” This guidance from the Vicar of Christ is not particularly “recent” (although our reader might have come across it recently), and it is perfectly consistent with statements from Popes John Paul II and Benedict XVI. Since the question first arose—as a result of medical advances that made it possible to sustain some vital functions indefinitely by artificial means—the Roman pontiffs have frequently expressed confidence in the ability of doctors to distinguish between life and death.

I don’t share that confidence. I am not questioning the teaching of popes. I am questioning the judgment of doctors. Not all doctors, certainly. There are many fine doctors whose judgment I would trust implicitly. But since the medical community as an institution has now made its peace with abortion, embryo research, and in vitro fertilization—and is taking a long look at assisted suicide—I am no longer willing to abide by the accepted moral standards of the medical profession.

If you read my earlier column, you know that I question the morality of removing vital organs from a patient who has been classified as “brain dead.” Recall, too, that “brain dead” donors are for all practical purposes the only source of unpaired vital organs for transplantation. Except in the rarest of circumstances, after an “ordinary” death, when the heart stops beating, the condition of vital organs deteriorates so quickly that they cannot be transplanted. 

Since I try to conduct my life in accordance with my own principles, I have notarized instructions on file, directing that I do not wish to donate my vital organs and that I refuse to accept a vital organ transplanted from another patient. But it would be misleading to suggest that every good Catholic must agree with me and take the same action. On the contrary, I realize that mine is a minority position. But I plan to continue arguing that position until someone persuades me that I am wrong.

In Evangelium Vitae, Blessed John Paul II described organ donation as “particularly praiseworthy.” When he was questioned about the morality of such donations, Pope Benedict XVI (then Cardinal Ratzinger) responded by showing his organ-donor card. 

Before I go any further, let me clarify what I am not saying:

• I am not saying that no one should consent to be an organ donor. Pope Benedict is (or at least was) a donor; I don’t plan to second-guess his judgment. I do think that everyone should ponder the decision carefully.
• I am not saying that anyone who has donated or received an organ should be condemned. If Pope John Paul considers donations “particularly praiseworthy,” who am I to quarrel? And if you have been the recipient of a successful organ transplant, I have no doubt that you acted prudently, based on the best information available to you at the time, and I thank God for your current good health.
• I am not saying that the Church must change her teaching. Quite the contrary; if the magisterium were to reject the arguments that I am putting forward, I would accept that judgment. But—here’s the crucial point—I don’t think the magisterium has spoken, or is likely ever to speak, on these arguments.

Last year my friend John Haas, the head of the National Catholic Bioethics Center, published a journal article in which he summarized the Vatican statements supporting organ transplants and accepting the use of “brain death” as an acceptable standard for determining that a vital organ can be removed. Insofar as he writes about what the magisterium has said on the issue, Haas makes a compelling argument. There has certainly never been any hint of a condemnation of organ transplantation, and there have been several clear signs of support for the “brain death” approach. For example in 2000, speaking to the Transplantation Society, Pope John Paul II said that it should be possible to establish that death has occurred by using neurological criteria.

The Pontifical Academy of Sciences has gone much further. As John Haas observes: “Thus three times now, under two different pontificates, the Pontifical Academy of Sciences has concluded that the neurological criteria are a legitimate basis for determining death. No pope, no discastery of the Holy See, and no official consultative body to the Holy See has ever called into question this conclusion of the academy.”

However, one must bear in mind that the Pontifical Academy of Sciences is a consultative body, not a teaching arm of the magisterium. Moreover, the results of the Pontifical Academy’s latest discussion of this issue are tainted, since—because of some intense jockeying before and after the session—critics of the “brain death” approach were not allowed to present their arguments. For an accurate understanding of what the teaching magisterium has said on this issue, it is better to rely on statements by the Roman pontiffs.

At first glance those statements seem to give the green light to the “brain death” approach. After all Pope John Paul II accepted the possibility of determining death by neurological criteria, and “brain death” is diagnosed by neurological tests. But notice that Blessed John Paul did not say which neurological criteria would be sufficient to establish death; he did not endorse any standard for determining “brain death.”

Speaking more generally, when he said that organ transplants are “particularly praiseworthy,” Pope John Paul added that they must be “performed in an ethically acceptable manner.” What are the standards that determine that an operation is ethically acceptable? John Haas points out that there is universal agreement on one standard—the “dead donor” rule. Before doctors can remove a vital organ, they must be morally certain that the donor is dead.

So we are back where we started. An organ transplant can be morally acceptable—indeed praiseworthy—if it is done by ethically acceptable standards. It is done by ethically acceptable standards if (among other things) the donor is already dead. But how can we be morally certain that the donor is dead? On that question, I submit, the magisterium is silent. In fact, if I read the words of Pope Pius XII rightly, the magisterium not only is silent but will remain silent. It is the duty of doctors, not bishops, to determine when death has occurred.

Pope John Paul II voiced his confidence that doctors could set neurological criteria for determining death. But the current standards for diagnosing “brain death” have been roundly criticized by some doctors, nurses, philosophers, ethicists, theologians, and even pesky journalists. Is it possible to maintain moral certainty that these criteria are adequate, when so many people remain unsatisfied? The first criteria for diagnosing “brain death” were introduced in 1968, after the success of organ transplants created a demand for healthy organs. Surely it should give us pause if death is declared for utilitarian reasons: to make transplants possible. 

Even John Haas, in his defense of the “brain death” approach, concedes that the necessary tests may not provide adequate safeguards in all cases: “It must be admitted that some physicians will not always be careful in the administration of these tests and may prematurely declare a person to be dead without properly ensuring that the criteria have been met.”

Exactly. When an organ transplant counts as a success, and the failure to obtain a vital organ may mean the death of another patient, doctors will always be under pressure to declare a potential donor dead. The “brain death” diagnosis makes it far easier for a doctor to reach that conclusion—and there are multiple different standards for “brain death,” creating confusion and multiplying the possibilities for abuse. In the early 21st century, when the medical profession has shown an alarming propensity for exploiting one human person to benefit another, we should demand more rigor in defining death.