Alexander Chen

Ethics of Removing Patients’ Hearts for Transplantation Immediately after Cardiac Death

Death is often looked at with fearful eyes, even though medical breakthroughs have prolonged it as much as possible. However, some individuals see death as another chance for life. Human organ transplantation has now become a routine operation; specifically, heart transplantation is an important leap for mankind, giving people the ability to live beyond death. However, not only is there a shortage of transplantable organs, but many seriously ill patients wait for months or longer to receive one.

Debates have been continuously argued over “what criteria to use to declare a person dead in order to remove organs. Current transplantation rules require that a person be declared brain-dead (irreversible loss of all brain functions) or suffer cardiac death (irreversible cessation of heart and respiratory function) before organs can be removed” (Levine 291). In August 2008, Denver physicians removed the hearts of three severely brain damaged newborns, but were not brain-dead by neurologic criteria, very soon after their hearts stopped beating. This brings into light the standards by which death is determined. The arguments about why patients should be considered dead have never been fully convincing. In the case study, some people believe that there is confusion of what it is meant to be ‘dead’. On the other hand, some argue that cardiac standards are flawed, and that a ‘higher-brain’ definition of death would be more suitable. Looking at this through Aristotle, Immanuel Kant, and Iris Murdoch’s perspective, it is possible to see this case through different viewpoints and determine which is the best method to approach in this situation.

Aristotle would bring into light the highest goods a human can have: a complete and fulfilled life, self-sufficiency, and the ability to act through reason towards virtue. According to Aristotle, attaining a sense of these goods leads to the highest form of happiness that humans can achieve (Irwin 3).  By missing one or another, true happiness would be unattainable. With this mindset, it would be reasonable to assume that patients who are near death, or have severe neurological damage, would be unable to achieve happiness. Patients with neurological damage are either in a state where they are no longer able to respond (a coma), or unable to perform the basic activities needed to be self-sustaining. In this sense, the patient is no longer self-sufficient, and does not have the ability to act through reason any longer. However, this is a debate within itself, for Aristotle leaves the term ‘complete’ vague and open to interpretation. Usually, the patient is the only person able to determine the fulfillment on his or her life. If a person has ‘completed’ his or her life, in whatever form or shape he or she believes the term ‘complete’ may be (Irwin 7), then Aristotle would support the removal of vital organs immediately after cardiac death, as there is no need to prolong the life any longer. However, if the patient did not ‘complete’ his or her life, Aristotle would want to keep the patient alive until the patient has reached the highest form of happiness.

Pertaining to the case study, the newborns had suffered severe neurological damage. However, because their life had only begun, it is hard to say what ‘complete’ is in their perspective. From an outsider’s point of view, one would say that the newborns did not have a complete life, and also had the ability to grow and achieve the state of self-sufficiency. This then leads to the newborns’ future capability of one day ‘completing’ and ‘fulfilling’ their lives. Aristotle would then argue that the newborns must be given a chance to live, and disagree with the immediate removal of the hearts after cardiac death. Yet, there is also another possibility. Hypothetically, there is the chance that the baby’s life is already complete, even though it may have only lasted for a short term. Aristotle never stated what the specific definition of ‘complete’ is, let alone set a deadline of when to finish. Therefore, it is also possible that the baby has already achieved the highest form of happiness, however different it may be. This would result in Aristotle’s decision to immediately remove the hearts from the newborns.

Happiness does not only apply to the donors, but to the patients waiting for transplantation as well. With over 100,000 people waiting for organ transplantation (Levine 291), many people have the ability to continue to live when given the chance. Aristotle states that “the good of the city is apparently a greater and more complete good to acquire and preserve” (Irwin 2). However, the term ‘city’ can be interpreted not only as an entity of its own, but as a group of people living together. Therefore, achieving happiness with more people is a greater goal than achieving happiness alone. Having an abundant number of organs available for transplantation would greatly preserve the happiness of the patients by allowing them to continue to achieve what they believe to be a ‘complete’ life. However, there is no evidence that the good of the city is served by the death of donor patients, as all of the points made are hypothetical situations. There is also the idea that people are unsure of what happiness truly is, and what deems as a ‘complete’ life. In addition, there is also the happiness of the patients to consider. If the donor patient has not achieved the highest form of happiness, then Aristotle would want the patient to continue to live, even if there was a chance to be resuscitated after cardiac death. This would result in the clash of happiness, and the question of which life is more valuable to preserve, if life can be measured through happiness alone. When the hearts were removed from the three neurologically damaged newborns, they were successfully transplanted into three different newborns, resulting in their continuation of life. Again, the issue of possible achievement of happiness comes into play, and the argument begins all over again.

Looking at this problem in Kant’s perspective, this issue applies to all three foundations of the categorical imperatives. Specifically, the difference between cardiac death and brain death applies primarily to the first categorical imperative: “Act only according to that maxim whereby you can at the same time will that it should become a universal law without contradiction.” The problem with organ transplantation is the difficult to specify the criteria that determines the death of the patient. Currently, there are two forms of death that physicians agree on: cardiac and brain death. With cardiac death, the viability of the heart is compromised after asystole, about 120 seconds. “In the waiting period, hearts are more likely than other organs to deteriorate from lack of oxygen” (Levine 291). Therefore, physicians are looking for the shortest amount of time needed to determine the death of the patient. This brings into light the possibility of changing the donor death rule to include brain death. However, many situations arise that complicate this even further, as having cardiac death does not lead to brain death, and vice versa.

In Kant’s perspective, if a choice had to be made between the two types of death, it must fit within the first formulation. As an example, if cardiac death was chosen as the universal law that determines death, then all patients who suffer cardiac death should have their organs immediately removed, ignoring the five minute waiting period set by the Institute of Medicine (Levine 291). However, this is a contradiction because if this were a universal action, then there is no point for resuscitation, as this would only interfere with cardiac death. Many medical advancements would be removed, such as the pacemaker, in order to follow the universal law. As a result, medical advancement would be severely hindered, as external stimulation no longer an option for resuscitation, and many people may die, even though they may have wanted to live. On the other hand, if brain death was chosen as the universal law for death, then patients who are brain-dead by neurologic criteria should have their organs removed, even if their hearts are still beating. This is no longer a contradiction because if this were a universal action, then patients who are in a permanently unconscious state would be considered dead; in this justification, patients who are in a permanent vegetative state, who also breath and grow, should be diagnosed as dead. While numerous people who believe brain-dead patients to still be alive would be outraged, this is a philosophical viewpoint that leads to a different decision by Kant. In addition, Kant would state that brain-death is also the removal of rational, which is a major part of determining the humanity of an individual. Without rational, the permanently unconscious individual is only a ‘thing’ instead of a person. Rather than agreeing or disagreeing with the ethical implications of immediately removing the heart after cardiac death, Kant would have the argument focus only on brain death, leaving patients who suffer cardiac death out of the equation.

Another problem that arises is the use of the term ‘irreversible’ when defining death. Definitions, although not universal laws, are types of universal substances, in a sense. In other words, definitions are accepted by everyone, as it is specifically state without any doubt. With this in mind, death, by definition, would also be a contradiction, as the interpretation has changed multiple times, and is argued over, as medical advancements continue. This is because the main focus is that ‘irreversible’ is an integral part of defining the death of a person. “If someone is pronounced dead on the basis of irreversible loss of heart function, after all, it would not be possible for heart function to be restored in another body.” Therefore, it can be further applied to defining death as the “impossibility of autoresuscitation, which means that the heart cannot restart spontaneously even if it could be started by means of external stimulation” (Levine 295). With this in mind, it can be stated that one cannot say a heart is irreversibly stopped if it will be restarted. Kant would see this as directly undermining the definition of ‘irreversible’, and would lead to the contradiction of death in itself. Therefore, Kant would argue that because there is no set universality of death’s definition, he must stay neutral in the ethics of immediate removal of patients’ hearts after cardiac death. However, because hearts can be externally stimulated to restart, “some experts have insisted that one wait until the heart cannot be restarted to pronounce death, a number of them pressing for waiting times of 10 minutes or longer” (Levine 296). While this is reasonable when determining the death of a patient, this also severely affects the condition of the heart. With the elongation of the time between asystole and the pronouncement of death, the viability of the heart is compromised, and can no longer be used for transplantation. Therefore, although having the waiting times increase to fit the definition of death, and also fitting into the criteria set by Kant’s first formulation, this will affect the number of available vital organs that can used for transplantation.

The case study states that the three newborns suffered cardiac death, but did not fulfill the requirements necessary for them to be considered brain-dead. In this situation, if Kant were to follow the first formulation with cardiac death as the leading form of death, then there would be great difficulty deciding over the removal of their hearts after cardiac death. However, if Kant were to believe brain-death was the universal law that determines death, then Kant would disprove of the removal of the neurologically damaged newborns, even though they had suffered cardiac death. Because the newborns are not brain-dead by neurologic criteria, this would go against the universal definition of death, in terms of brain death. In addition, if Kant were to follow the universal definition of death and irreversible, removing the hearts from the newborns would be disagreeable, as the hearts from the donor newborns were used and successfully transplanted into three different newborns.

Murdoch focuses on the attention of an individual, and how that attention is used when following moral duty. However, attention can be applied not only to other people, but to concepts and ideas as well. In this case, there is a great deal of attention to what death means. “Before the development of modern critical care, the diagnosis of death was relatively straightforward: patients were dead when they were cold, blue, and stiff” (Levine 292). In this era, the extent of attention to death was at its peak. However, with the revision the definition of death by Henry Beecher, there needs to be greater attention directed towards the interpretation. The understanding of death is problematic at several levels. The cardiac definition of death requires the “irreversible cessation of cardiac function” (Levine 293). Because the common understanding of ‘irreversible’ is ‘impossible to reverse’, this creates the paradox that the hearts of patients who have been declared dead due to irreversible loss of cardiac function have been transplanted and successfully restarted in the body of another. Not only does this confuse people of what ‘irreversible’ is, but also brings up the issue that the donors may have had the potential to be resuscitated. Another problem is the reliance on the dead donor rule, as it has the potential to undermine the trust in the transplantation enterprise than to preserve it. It shows the possibility that the medical profession has been changing the definition of death to conform with the conditions most favorable for transplantation. Although Murdoch states that paying attention is an important part of moral duty, she also states how it is an imperfect and continuous process. Therefore, it is reasonable, in Murdoch’s viewpoint, that there are still flaws in the understanding of death. This would lead to the neutral point of view with the case, as there is not a sufficient understanding of death, and the impact is has on patients.

It is also important for Murdoch that there is a great detail of attention made by doctors and their patients. Doctors must pay attention to both sides of the groups: the donor patients and the receiving patients. For donor patients, doctors must be able to see not only the physical ailment that leads to the consideration of organ removal, but also the mental capabilities of the individual. Although some patients may suffer cardiac death, the doctor must also pay attention to the patients’ ability to live, and the previous life of the patient. In a sense, the doctor must understand the value of the person’s life; as a result, this would cause doctors to have a much more difficult time determining the time of death. However, if doctors were to solely pay attention to the patients receiving the organ transplantation, then the doctors will also learn and understand the value of the patients’ life. Determining when death occurs would be simple, as the doctor would attempt to retrieve as many transplantable organs needed for the patients who require transplants. Yet, because the doctor must use his or her attention of both patients, it is hard to determine which life is more valuable. In other words, the doctor is faced with whether to immediately remove the organs from the donor patient and transplant it, or to have a certain waiting period in order to open the possibility of the donor patient recovering from cardiac death.

In the case study of three newborn, Murdoch would ultimately agree with the immediate removal of the heart after cardiac death. Although there were many controversial aspects of the situation, it was concluded that “‘the three babies are now alive; had the procedures not been performed, it is virtually certain that all six babies would be dead’” (Levine 298). With this information at hand, it would be safe to assume that there was an understanding of the conditions of the newborns, and the unlikely-hood of their survival if organ transplantation was not performed. However, because this information was only discovered after the transplantation, Murdoch would continue her neutral standpoint before the operation occurred.

Organ transplantation has brought up many controversial debates on the ethics of organ removal and viability of organs. Of the three philosophers, only Kant is able to determine an answer. However, this answer is different than agreeing or disagreeing, as he offers a different approach to seeing death instead of cardiac death. Aristotle and Murdoch are both neutral, with a common view that there is not enough evidence to determine both ‘complete’ and ‘death’. Without it, it is impossible for the two philosophers to make a stance on the ethical implications. Yet, pertaining to the specific case study with the three newborns, Kant would disagree in the removal of the hearts, Murdoch would agree with the removal, and Aristotle would continue with his neutral viewpoint. This is because Kant defines death as brain-death, and would see that the newborns are not brain dead by neurologic criteria. Murdoch sees that there is an understanding in the fact that all six newborns would die if no transplantation occurred, and would agree. It must be understood that her agreement only applies to this scenario, and because there was information revealed after the death of the three neurologically injured newborns. Aristotle would continue with the hypothetical situations, and find it difficult to determine the ‘complete’ life of the newborns. Therefore, if a ethicist was to view this case study in a general sense, then Kant would have the most definite answer. However, if the ethicist was looking at the case study with the three newborns, then there would be disagreement between Kant and Murdoch’s stance on this issue.