From the 3rd September 2008 daily edition of The Roman Observer. The translation is my own, and in cases where I couldn't understand the Italian I've tried to render the English similarly incomprehensible. I will claim, in the case of inaccuracy, that my translation is divinely inspired or something. I'm publishing the full text because I doubt that there's going to be any other way to get hold of it after the end of today.
Signs of Death
40 years since the Harvard report
Forty years ago, towards the end of the summer of 1968, the so-called Harvard report changed the definition of death to be based no longer on cardiocirculatory arrest, but on a flat encephalogram: from that point the organ indicating death was no longer just the heart, but also the brain.1 This involved a radical change in the conception of death - which resolved the problem of the disconnection of artificial respiration, but that more than anything made possible the transplant of organs2 - accepted by almost all developed countries (where it is possible to realize these transplants), with the exception of Japan.3
Also the catholic church, in allowing organ transplants, implicitly accepts this definition of death, but with strong reservations: for example, certification of brain death is not used within Vatican City.4 The philosopher of rights Paolo Becchi now reminds us of this fact in a book (Brain Death and Organ Transplants, Morcelliana) which - apart from going over the history of the definition and of the debates which followed during the '70's, amongst which the most important is without doubt that in which the protagonist was Hans Jonas5 - faces the current, much more complex and controversial, situation clearly.6
The motive for which the new definition was accepted so quickly is found in the fact that it was interpreted not as a radical change in the concept of death, but only - writes Becchi - as “a consequence of the process of technology which has made available to medicine more accurate instruments with which to measure the loss of cerebral function.”7 The scientific justification of this choice sits in a peculiar definition of the nervous system, today put back into discussion by new research, which puts into doubt specifically the fact that brain death provokes disintegration of the body.8
As the sensational case of a woman who went into an irreversible coma and was declared brain dead before it was realized that she was pregnant demonstrated in 1992;9 it was decided to let the pregnancy continue, and this continued normally until a miscarriage.10 This case and others like it concluding with the birth of a baby have put into question the idea that in this condition one is dealing with a body which is already dead, cadavers from which organs can explanted.11 It seems, then, that Jonas was right when he suspected that the new definition of death, more than from a true scientific advance, was motivated by interest, i.e. from the necessity of organs to transplant.12
Naturally, on this subject a dicussion has openedin the scientific world, partly summarized in a volume, curated by Roberto de Mattei, Finis vitae. Is brain death sill life? (Rubbettino), in which contributors13 - European and American neurologists, jurists and philosophers - agreed to declare that brain death is not death of a human being. The risk of confusing a coma (cortical death) with brain death is always possible.14 It is this worry which came to be expressed at the extraordinary assembly of 1991 by Cardinal Ratzinger from his report on the problem of the menaces to human life:15 “Later on, those for whom illness or accident causes to fall into an ‘irreversible’ coma, will always be put to death to fulfill the demand for organs to transplant or to be used for medical experimentation (‘warm cadavers’).”16
These considerations obviously lead to new problems for the catholic church, in which acceptance of the withdrawal of organs from brain dead patients, within the framework of a total and absolute17 defence of human life, is supported only upon the presumed scientific certainty that they are effectively cadavers. But putting the Harvard criteria into doubt leads to other bioethical problems for catholics: the idea that a human person ceases to exist when the brain no longer functions, while his or her organism - thanks to artificial respiration - is kept alive, carries an identification of the person with only the activity of the brain, and this enters into contradiction with the concept of a person according to catholic doctrine, and thus with the directives of the church when dealing with cases of persistent coma.18 As Peter Singer has pointed out, who takes a position opposed to the catholic one: “If catholic theologians can accept this position in the case of brain death, they should be able to accept it also in the case of anencephaly.19
Making a point on the question, Becchi writes that “the mistake, always more obvious, has been that of having wanted to risolve a legal-ethical problem with a presumed scientific definition,”20 while the knot of the transplants “will not be resolved with a medico-scientific definition of death,” but via elaboration of “ethically and legally sustainable and sharable criteria.”21 The Pontificia Academia Scientiarum - which during the '80's was in favour of the Harvard report - in 2005 returned to the theme with a meeting on “The signs of death“. The 40th anniversary of the new definition of brain death seems therefore to reopen the discussion, whether from the point of view of general science, or the catholic ambit, within which the acceptance of the Harvard criteria come to constitute a decisive hook for many other bioethical questions which are on the carpet today,22 and for which at the same time is worth putting back into discussion one of the few points on which laity and catholics have agreed in the last decades.23
- It really said “no longer just the heart” [non è più soltanto il cuore]: cardiac arrest is of course relatively easy to detect but it only causes actual death a few minutes later (longer in the case of hypothermia) because it stops the blood (and therefore oxygen and glucose) flow to the brain. With cardiopulmonary bypass the heart can be stopped, operated on, and restarted.
- Because if you wait for a dying person's heart to stop naturally before trying to transplant it, you'll find that it's irreparably damaged from oxygen starvation. It's better to stop a beating heart suddenly with potassium chloride.
- I don't know what the point about Japan is.
- I doubt that there is an eletroencephalograph machine in the whole Vatican, and certainly when Pope John Paul II was became ill at the beginning of 2005 he was taken to hospital in Italy. It's probably not the case that, when he died in his apartment in the Vatican, death was established by tapping his head with a little hammer and calling his name.
- I don't know what this is about either.
- Which is more than this article does.
- It's the other way around - instruments which are able to measure brain function show that if the heart stops the brain can keep going for a few minutes and there is a chance that the circulation can be maintained and the heart eventually restarted (although the chances aren't as great as American medical dramas would have you believe).
- What research? The UK uses Brain stem death as its definition - how more dead could someone be? If a person needs advanced life support to keep them “alive” then we have already gone well beyond what would naturally be considered life.
- I don't know what case this is exactly, but it might be the “Erlanger baby”.
- In other words, it succeeded up until it failed.
- The fœtus is kept alive by the life-support system attached to the mother.
- Yes, curse those doctors with their selfish desire to get their hands on a dead person's organs and use them to save someone else's life.
- From only one side of the debate, it seems.
- See note 8.
- Sorry for the convoluted formulation, the Vatican really does write like this.
- See note 12. It's not like doctors are tearing the still-beating hearts from young virgins and devouring them or something. (It's the catholics who eat flesh and drink blood.)
- Total and absolute anything always leads to problems, but I hope it's only going to be a problem the next time a cardinal needs a new kidney.
- Obviously the church should update its directives, but I have the feeling that they've been waiting for some non-consensus medical opinions to be expressed so that they could seize hold of them and claim that they were right all along.
- Well I don't know what Peter Singer's position is or what point that quote is trying to make.
- Is the problem not one of trying to apply medieval intuition to a modern medical and scientific question?
- Well it won't be resolved, as far as the catholic church is concerned, with a “medico-scientific definition of death” as long as the catholic church feels the need to question that definition on vague spiritual or doctrinal grounds.
- It really does mention a carpet, or rather a rug [tappeto].
- In other words, “we sense that we can exploit the emotional response of the laity here and win back some influence”.
This follows on from the catholic church basically spoiling it for everybody with their opinions on persistent vegetative states (Eluana Englaro, for example) and terminal diseases. A recent example was the case of Piergiorgio Welby, a muscular dystrophy sufferer who was volutarily euthanized in December 2006, after having been unable to breathe naturally for about eight and a half years. The church denied him a religious funeral.
Someone wrote to Viz recently to point out that when we talk about “Acts of God” we usually mean bad stuff such as earthquakes and hurricanes which cause terrible devastation to life and property, while “Playing God” usually means that health professionals or biologists are trying to improve quality of life, often by trying to research or correct some sort of genetic mistake or developmental error, which one can only assume, if one believes that God does anything at all, was made in deliberately by God for some unknown (but probably unpleasant if you really think about it) reason.