Organ Donations: A Christian Family Physician's Perspective - Dr. Greg Kenyon M.D.
I have been a Family Physician in Mitchell, Ontario for the past eight years, and in my training I have had exposure to organ donations, both in the classroom and on the hospital wards. In my surgical rotations I took care of some of these patients, although I don't remember assisting at any major transplant surgery, I did have stirrings of concern in my conscience but I did not seriously consider this issue before God. Two of my patients in Mitchell have had major transplants. One was a diabetic who received a cadaver kidney ten years ago. He died recently after failure of the transplanted kidney. The other is a young girl, who is doing well ten years after a liver transplant. With these I was not directly involved in the decision to proceed with the transplant. Also, I have never been sure it was right to have signed the donor portion of my drivers licence. This was in part out of ignorance, having never studied the issue thoroughly. Over time, the stirrings from my conscience have grown, directing me to the need of having to search the Scriptures to be sure that what we are doing is right before God.
My more common exposure to organ donation includes; transfusions of blood products and cornea transplants. With these I have simply accepted what I was taught during my training as being right. Growing as a Christian involves re-evaluating many practices and beliefs in light of God's Word. It is interesting that it took the seemingly big things, like liver or heart transplants, to make me consider more seriously what the Bible teaches about the seemingly smaller things, like blood transfusions and cornea transplants.
He that is faithful in that which is least, is faithful also in much: and he that is unjust in the least is unjust also in much. (Luke 16:10)
We are encouraged by Jesus to take no part of our lives for granted. We should be working everyday, to know the Scriptures and to know what the Scriptures teach in all areas of life.
I will try to bring the need to apply the Bible to organ donation closer to home with the following story.
In your congregation there is a thirty-nine year old father of seven young children who has insulin-requiring-diabetes. Traditional treatments of diabetes will likely result in long term complications including eye damage, kidney damage, nerve and feet damage, and result in disability while he is still in an active stage of life. You have been told that through a recent development it looks like He could be cured.
With today's technology, doctors are saying that it is possible with a simple injection to implant some human insulin producing donor cells. A breakthrough has opened the possibility for many diabetics to be treated. After studying many aborted fetuses they have managed to have fetal insulin producing cells reproduce themselves in the lab. Now millions of cells are available.
You have learned that this member of your congregation is planning on having this procedure. You are visiting with him to express your concern. He tells you he has thought and prayed about this a lot, although he admits that you are the first person he has talked to. He says that he realizes that the original cells came from an intentionally aborted baby but the actual cells that he will be getting are produced in the lab. He knows that abortion is wrong but having this procedure will not require the abortion of another fetus (unborn baby). He would not have encouraged abortion in the first place and believes that if God's law had been honoured by the scientists, God would have provided the cells to cure diabetes by another means. He sees a similarity between this sin of abortion and David's sin of adultery with Bathsheba. David's sin was wrong but God allowed the line of Christ to come from it. So, God allows a good treatment to come out of the sin of an abortion. His wife is not too sure but is willing to submit to her husband and keeps thinking of losing her husband while their children are still young.
Now it is your turn. They are now sitting quietly awaiting your response. Although you may not be sure about the rightness or wrongness of the procedure there are many issues which ought to be explored. More information is needed. Where did this father get his information from? Is it accurate? Has he considered godly counsel? Is his assessment of what the Bible teaches correct? Has he listened to his wife's thoughts?
This example is not unrealistic. I am a member of a Free Reformed Congregation who as a thirty nine year old father of seven young children have insulin-requiring-diabetes. Although this treatment with fetal cells is not readily available, it is possible. Another issue, I may personally have to face, is a kidney transplant since diabetes is the leading cause of kidney failure for which transplantation is considered a treatment of choice. How do we respond when expected to give counsel about these things? How do we decide what is right?
The topic of organ donation holds a certain sense of appeal. The technology is exciting, the results so amazing, that we must wonder at God's creation. On the other hand, the part of organ donation that challenges the boundaries between life and death ought to be repulsive to us.
As we consider the issues surrounding organ donation when counselling our brother, we may focus so narrowly on the rightness or wrongness of what our brother is planning that we fail to focus on what is most important. Is this not how the pharisees failed? They studied until they thought they knew all the rules and focussed on the keeping of rules rather then on the condition of the heart.(1) To guard against this error we need to keep at the forefront of our minds the task that is before us. Consider Paul's example in 2 Corinthians 5. He says that he no longer considers anyone as the world does. Paul considers his brethren as Christ does, as new creations.
Paul and his brethren have the ministry of reconciliation. He says, "Now then, we are ambassadors for Christ, as though God were pleading through us." He sees his task as that of imploring his brethren to be reconciled to God.(2) As we consider the issues laid before our brother, such as the pressure to donate or receive organs, our response should take into account the needs of his heart. We need to consider how the opportunity can be used to guide our brother closer to our Lord.
Although the condition of our brother's heart is most important, we still need to consider the finer details of organ donations. Paul instructs us to "Test all things and hold fast to what is good."(3) We are to find out what is acceptable to the Lord and have no fellowship with the unfruitful works of darkness, but rather reprove or expose them.(4) This requires, first, that we know and desire to follow the Word of our Lord. Like Timothy, we need "to study to show ourselves approved unto God, as workmen that need not be ashamed, using the Word correctly".(5) We must know something about the world, in order to expose "the unfruitful works of darkness". We need knowledge about organ donations so, with the guidance of Scripture, we can determine what is fruitful and what is not.
One challenge is that "the deceiver", "that old serpent called the Devil and Satan who deceives the whole world",(6) is doing what he can to hide from us the immoral aspects of organ donation. The world tells how organs save lives and bring good from the death. It does not tell us about forty years of experimentation on aborted fetuses (babies). For these reasons I hope to spend significant time looking at the facts of organ donation. We will consider, in the light of Scripture, if it is permissible use part of one person in the body of another. If it is permissible, in what circumstances is it so? We will consider in some detail the definition of death and consider how society is redefining death to suit its purposes. I hope what is presented can help you consider how we should respond to these things.
Before proceeding I want to reflect, with some sadness, on how far behind and unprepared the church of our day seems to be in responding to the issues before us. I hope this may spur you on to run the race that is before us and to fight the good fight.
The Slippery Slope
Through my study I have become much more concerned about the moral problems surrounding organ donation. I found the ethics of organ donation and of the declaration of death have a prominent place in the secular forum. Sadly, I did not find much from the churches that compared it to the Word of God. Jewish and Catholic views were much more easily found then Protestant. The National Kidney Foundation published a list commenting on the position of each major religion on organ donation. Although this information is from 1979, it is still used today. This list claims that Lutheran churches endorse organ donation; that Presbyterian churches encourage and endorse organ and tissue donation and
"they respect individual conscience and a person's right to make decisions regarding his or her own body."(7)
This ought to alarm us when we consider that "we are not our own we are bought with a price and belong to our saviour Jesus Christ."(8) We do not have a right to do whatever we want with our own body. Any decision about what to do with our body must be solidly based on the Word of God. For it has given us all things that pertain to life and godliness."(9)
The Presbyterian Church of Canada's official response to organ donation is from 1969. It accepts the declaration of brain death given by a Neurologist, without any appeal to Scripture saying, "From the aspect of the donor, there seems to be no moral problem but supply". With respect to deciding who gets an organ they say, "this decision, we feel, is left in competent hands", meaning physicians.(10)
Consider the decision making process used by physicians in respect to organ donation. A 1989 survey of 195 physicians and nurses, from intensive care units and other settings where organ donors might be found, shows there is considerable uncertainty over exactly how brain death is defined.(11) Physicians continue to debate the diagnosis of brain death.(12) More recently there is increasing pressure to loosen the definition of brain death. Physicians have started the questionable practice of "non-beating heart" donors. ("non-beating heart donors" will be explained later.) Physicians are involved in abortions and are using fetuses in transplant research. What does our Lord think of this? Why is the cry of alarm not great?
In order to respond, we need to become more aware of what is happening. To emphasize the need for awareness, I quote the introduction to a paper titled The Slippery Slope, by a Chatham, Ontario, Family Physician, Dr. John Stronks. He writes,
Not so long ago I was having a conversation with an obstetrician who performs abortions, sharing my excitement about the birth of apparently healthy twins at a gestational age of 28 weeks. He responded with disdain, asserting that we have gone too far in trying to save such infants. After all, what if they grow up to have a learning disorder, he mused.
Earlier in my career I was taken aback when asked by 13 and 14 year olds for contraception. Now I take the fact of teenage sexual activity for granted. Recently, I was taken aback again when a foursome of teenagers presented with a question pertaining to the sex act. Will there come a time when I take the fact of group sex for granted as well?
We have witnessed in our society a rapid progression from the legalization of divorce to the realization of widespread family breakdown. Feminism has yielded to witchery and other sorts of new age religion. Homosexuality has come out of the closet and now is in the forefront of the legislative agenda, even to the extent that some are advocating the legalization of homosexual adoptions and the recognition of paedophilia as normative. We have witnessed the liberalization of abortion laws only to be faced with the wholesale slaughter of tens of thousands of infants annually and emergence of issues such as euthanasia, assisted suicide, and mercy killing. Just a few years ago government run lotteries were introduced; now gaming has become big business for government and a normal source of entertainment for many Canadians, even for many Christians. What was once pornography is now standard fare for advertisers and movie makers. And while young children are indulging in their parent's collection of pornographic videos, we still wonder why we now almost daily hear news reports on serial sexual predators.
This is a sad, but true reflection on Canadian society. And it is disturbing, especially for Christians who are feeling increasingly repressed as a minority voice in the shaping of Canadian society. Like never before, Canadian Christians have been challenged to think about moral issues, to search the Scriptures for relevant insights, to formulate positions and responses. To this end, it is my desire, as a Christian physician to share some of my experiences and insights.(13)
I can echo the words of Dr. Stronks. It is within this society that we must face pressure to come up with increasing numbers of viable organ donors. Dr. Stronks goes on to consider how our society and Christians have becomes so accepting of this ever growing tide of immoral action. It is the result of the destructive, progressive, aggressive nature of sin. If we want to bring the true light of the Gospel to the world, we must resist the temptation to compromise God's standards and we must reject the flawed morality the world presents. To keep from falling into this temptation, we must not allow sin lead us down the destructive, progressive path of accepting the immoral as moral.
Is human organ transplantation permissible?
We will begin by considering the question, "Is the use of part of one person in the body of another person permissible?" If it is not permissible, then all organ donation is wrong.
In Christian circles, including our own, using part of one person in another is generally accepted. Most of us accept blood transfusions and cornea transplants without concern. On the other hand, some of us may question a heart transplant. Is there a difference?
God created each of us as a unique being. Every cell in our body, except red blood cells, have a DNA blue print containing all the information needed to fully describe the physical parameters of our body. This fact makes every organ absolutely unique. Every organ, even after a transplant, keeps its DNA blue print that links it to the body it came from. The absolute uniqueness of every single organ in the world is one of the things that makes organ transplants difficult to do. Just as every heart is uniquely designed to best suit the body it was made in, so it is with every cornea. From the point of view of this created uniqueness there is no difference between major organs such as the heart, lungs or liver, and seemingly less important organs like corneas. This principle can also be applied to the body of Christ. Christians are individually regenerated and recreated to become uniquely suited to form the body of Christ.(14) Together the members of Christ's body possess all the information needed to identify Christ according to the DNA blue print of the Holy Spirit.(15) The importance of every individual and the necessity of each member of the body is described in 1 Corinthians 12:12-26.What are the implications of putting an organ, uniquely designed for a certain person, into a body that it was not designed for? Does God create organs that are uniquely designed for one person that He intends to be used in another person?
Although Scripture does not speak directly on this issue, it contains principles that may promote the use of organs for transplants. The greatest example can be seen in the work of Christ. He used the very essence of his being to give life to others. In another example, the good Samaritan, who helped the man that fell among thieves, took of his own resources and gave them to a man who was half dead, in order that the man might be restored to life (Luke 10:30-37). Also, the Apostle Paul, in his letter to the Galatians, reminds them of how greatly they cared about Paul in his weakness saying, "if it had been possible, ye would have plucked out your own eyes, and have given them to me." (Galatians 4:15) In that day donating ones eyes was not possible but Paul seems to be commending the desire to donate them. Our bodies are given to us by God to be used according to his will or in the terminology of Paul, "to magnify Christ....whether by life or by death" (Philippians 1:20). If it is God's will that we help someone by giving them an organ that God has given us, then Christ will be magnified.There is one bible passage that appears to teach against using living organs of either human or animal origin. In Acts 15:1-20, when the elders of the early church came together to consider the issue of circumcision in salvation, James says,
Wherefore my sentence is, that we trouble not them, which from among the Gentiles are turned to God: But that we write unto them, that they abstain from pollutions of idols, and from fornication, and from things strangled, and from blood. For Moses of old time hath in every city them that preach him, being read in the synagogues every sabbath day.
This speaks against taking in blood. This appears to teach that blood transfusions and transplantations of any organ that contain blood are not permissible. Historically this is not how the Christian church has interpreted this passage, as is evidenced by our acceptance of blood transfusions. The notes of the New Geneva Study Bible suggest that this was not a command but encourages both the Jewish and Greek Christians to practice moderation. The Jewish Christians are to recognize that Gentiles are not to be bound by Jewish ceremonial law. The Gentile believers must consider the scruples of the Jewish Christians, which were shaped by the laws of Moses, and not offend them by eating food sacrificed to idols, eating meat of strangled animals, or blood.(16) Matthew Henry, concurred with the statement that things strangled and containing blood were not evil in them selves nor were they designed to be always abstained from as were those things which had been forbidden by the precepts of Noah before the law of Moses.(17) So far, I am not convinced solely by Scripture that there is no concern about this use of blood. For now I will accept the conclusion of the Christian church that this precept of Moses does not prohibit blood transfusions or organ donations.(18)Next, some may be concerned about the impact, of transplanting an organ from one person into another in reguard to the resurrection of the body? Can we live in the expectation of the resurrection of the body and give away one of our organs? God tells us that we are dust and unto dust we will return (Genesis 3:19, Ecclesiastes 3:20 Job 34:15). As dust our bodies do not remain together in the grave. Many graves have had their dust washed away and spread out by the forces of nature. The fact that the dust of our ancestors does not remain in one lump over time, will not stop God from resurrecting their bodies. Daniel 12:2 says, "many of them that sleep in the dust of the earth shall awake, some to everlasting life, and some to shame and everlasting contempt."
If it is our bodies, as we know them, that shall rise then all the molecules that make up "us" will have to come together. If this is true, there must be in the dust of the earth one set of molecules representing every person that has ever lived, since all shall rise in the last day. This would mean that even if part of our body was separated from us before death and put in someone else, the molecules that represent our body would still exist and could be brought back together in the last day. Loss of an organ or replacing an organ would not remove from the dust of the earth the molecules that represent us. Organ donation would not hinder the resurrection.
Yet, I believe this way of thinking is too simple. Heaven and earth as we know it shall pass away (Matthew 24:35) Paul responds to the question, "How are the dead to be raised?", showing us that the bodies of Christians, that are raised, will not be exactly like the bodies that died (1 Corinthians 15:35-49) These bodies are sown in corruption (1Cor 15:42) and will be changed and raised in incorruption (1Corenthians 15:51-52). The imperfections represented in the dust of the earth will not prevent the Lord from making all things new (Revelation 21:5).
On a similar note, some may be concerned about the issue of burying the dead without one of the major organs. We have seen that the actual burial of the body as a complete unit is not necessarily required for the resurrection. In support of this, consider Christians burned at the stake or drowned at sea. There are only a few instructions in Scripture about burying the dead. Jesus says, "let the dead bury their dead." (Matt 8:22, Luke 9:60) The person Jesus is speaking to was placing higher priority on burying the dead than on following Jesus. In Deuteronomy 21 there is a command to bury the same day someone who was condemned to death by hanging on a tree so that the land would not be defiled. In Genesis Abraham refers to the burying of his dead as "putting the dead out of sight" rather than giving them a resting place. (Gen 23) Joseph's instruction was to make sure his bones were taken up out of Egypt (Gen 50:25. Ex 13:19). His request was about his bones rather then all of the dust that came from his body. It seems that burying in the Bible was done more for the living, to put the body out of sight, to keep the land pure and to be used in a symbolic way. It does not seem that the details of, or actual method of, the burial was important as a precursor to the resurrection.So, we find that, in principle, organ donation is not absolutely forbidden by Scripture, that there are some scriptural principles that may promote it, and donating an organ should not hinder the resurrection of the body.
Under what circumstances is it permissible?
Having decided that the general principle of organ donation is not necessarily wrong, we now need know under what circumstances it is permissible. First, we will touch on differences between various organs. Then, we will focus on different types of donors. Significant attention will be given to the definition of death, as this is pivotal to most major organ transplants.
1. Based on type of organ.
First, consider the various types of organs that have been transplanted, including; heart, lung, liver, pancreas, kidney, heart valves, corneas, bone marrow, bone, skin, blood products, and some brain cells. Bowel transplants have been attempted but I don't think there has been any successes. Setting aside how the organ is retrieved from the donor, is there anything inherent in any of these organs that sets it's transplantation apart as being right or wrong?
Does the bible give any organs special status in a physical sense? Apart from the symbolic value that different organs have, I don't think there is any passage that places a special physical importance on one organ over another. The heart portrays a very unique symbol because physically the heart is the driving force behind the movement of the blood or the life of the body.
Corneas may be distinguished from all other organs because they are bloodless. This may give them special status, if the issue of transplanting organs with the life blood is considered to be important. The group of organs that are essential for life have a physical importance. These organs include; the heart, liver, pancreas and brain cells. If any of these are removed, the person they are removed from can not survive. This is a problem if they are taken from a living person as this would violate the sixth commandment.
All organs are useful to transplant, only if their cells remain viable. By viable, I mean the cells of the organ are able to continue to perform their function. This means the cells must be alive. Once a cell in our body dies it can not be brought back to life, by natural means. For the function of the dead cell to continue it must be replace by a new living cell. This means that every successfully transplanted organ has living cells in it at the time it is transplanted. Once the lifeblood (Gen 9:4) is cut off, organs die at different rates. The rate cells die depends mainly on the cell's energy requirements and the ability of the cell to turn its metabolic rate down to save itself. All cells can be slowed down by cooling.
The organ most sensitive to the loss of blood circulation is the brain. Its cells begin dying within four minutes of circulation failure. Next, are the liver, and pancreas. The kidneys and heart can survive a short time without blood supply, although they are likely to be scarred and not function as well. Skin and muscle can survive a few hours and corneas can survive several hours.
The shorter the time it takes for damage to occur, the less useful the organ will be if the heart stops beating. This leads into our consideration of the different types of donors.
1. Based on the type of donor.
Based on the circumstances of organ retrieval some clear distinctions exist between various organ transplants. How the organs are obtained is the most controversial issue surrounding transplantation. For example, a kidney donation from a willing living donor, such as the recipient's brother, may be right. Whereas, most would agree it is wrong to use a kidney from a criminal whose life was sacrificed in order to obtain organs. According to the news this happens in China.(19)
As we consider how organs are obtained, we will review various donor types including; clearly dead or cadaver donors, questionably dead donors, living donors, use of fetal parts (from aborted babies), and animal donors. Notice that the different types of donors are distinguished by their relationship to death. Therefore, we need to consider the definition of death.
Generally, we can be certain death has occurred if there is an irreversible loss of breathing, circulation, and all signs of brain activity. These donors I will classify as clearly dead.
The heart, lungs and brain seem to be the major organs governing the principal signs of life. They are the sources of circulation, breathing, and direction. Any of these may stop functioning for a period of time and later be restored. Circulation and breathing, indeed, can be maintained by artificial means.(20)
Resuscitation and Life Support, used when a person's breathing or heart has stopped evokes questions about traditional definitions of death. A study of death in the Bible does not seem to help us define death. John Frame in his book, Medical Ethics says,
Scripture does not formally define physical death but assumes that we understand what it is. Clearly, however, Scripture does recognize a point at which efforts to save a person's life, even by prayer, are to be abandoned (2 Sam 12:19-23). If there is any criterion of death noted in the scripture accounts, it would be cessation of breathing, though Scripture does not present this as a technical criterion but simply a matter of empirical observation. (Josh 11:11; 1Kings 15:29; 17:17; Job 27:3; Ps 104:29; Isa 2:22; Gen 2:7; 6:17; 7:15, 22; Eze 37:5; Acts 17:25).(21)
With respect to breathing, circulation, and brain activity He says,
The heart, lungs and brain are mutually dependent. The brain requires oxygen and blood; lung operation requires blood and brain-direction; heartbeat requires oxygen from the lungs, which in turn are dependent on brain function. Therefore, when one function is lost for a long enough period of time, the others will be lost as well. But, again, complications arise when functions otherwise lacking are maintained artificially. One can not really tell if a patient has lost lung function unless the patient is removed from life support.
This ambiguity encourages using death of the brain to define death of the person. As we will see, donors pronounced "brain dead" while the body is still living are desired by proponents of organ transplants. I will classify these as questionably dead donors.
a. Clearly dead donors
Having described what is meant by clearly dead and by questionably dead donors we can now look at each special type of organ donor. First, the clearly dead or cadaver donors are those with no question that death has occurred as, all signs of circulation, breathing, and brain function are absent for a long enough time. The only human parts that remain useful in this situation are skin, bone, heart valves and corneas (from the eyes).
Skin and bone can usually be obtained from the patient or from a living donor. Pig and synthetic heart valves are so successful that human heart valves are not used. In practice corneas are the only human parts used from clearly dead donors. As long as the eyes are removed within eight hours of death the corneas can be used. Since the process of decay of the body has begun in a clearly dead person, meaning, as we will see later, that the soul has departed from the body, thus it is not a violation of the person to take the corneas.
b. Questionably dead donors
All major organs such as, heart, lungs, liver and kidneys are very sensitive to loss of blood circulation. These organs can not be successfully transplanted from clearly dead donors because to be successful the organs need to be alive.
In a clearly dead person, the heart has stopped. The blood flow stops when the heart stops and the blood begins to separate and blood cells clump together into clots. This process is described in the Bible when the soldiers pierced Christ's side and water and blood came out, indicating that Jesus was really dead.
Once the blood clots, it becomes impossible to clear these clots out of an organ's very small blood vessels. If such an organ was transplanted a lot of its blood vessels would be blocked and not available to the recipient's circulatory system. To overcome this problem the blood must be replaced with preserving fluid at the time of removal.
Also, the cells of these organs are very dependent on a steady supply of oxygen and other nutrients. Once the blood flow stops, cell damage and cell death quickly follow. Cells of the non-cooled brain are irreversibly damaged within four minutes of no blood flow. It does not take much longer for other major organs to be damaged beyond repair. To overcome this problem specialized cooled replacement fluids are put into the organ while the donors blood is still flowing or almost immediately after the blood has stopped flowing.
Therefore, most major organs are taken from a donor with a beating heart. In practice a donor is declared brain dead in an intensive care unit, often after some form of trauma such as a car accident. Those in intensive care units due to disease, rather then trauma, are usually not suitable as donors because of the disease process. Once declared brain dead, the heart continues to beat on its own and breathing is maintained by a machine. While still on the machine, the donor is taken to the operating room. Breathing and circulation are maintained while the organs are dissected from the body. The last thing disconnected from the organ is the blood supply. At the same time, the blood in the organ is replaced by a cooled preservative fluid. Then, there is a rush to get the organ into the recipient so the recipients blood can provide what is needed to keep the organ alive. This needs to occur within hours. The longer it takes the less likely the organ will survive.
If the use of live body parts is considered appropriate, the main ethical issue with donation of these major organs is with the declaration of death. Unless we resort to taking organs before death is declared, we need to be able to declare death while the heart continues to beat for these transplants to succeed. Declaring "brain death" while the body is still alive meets this need.
"Brain death" is a relatively new term. An ad hoc committee of the Harvard Medical School first proposed brain death criteria in 1968.(22) This committee described criteria to define the irreversible loss of function of the whole brain. Using these criteria the survival of the brain is very unlikely but, as we will see death of the brain does not necessarily mean death of the person. It is only when the brain is effectively cut off from the other two determinants of life, breathing and circulation, that we can be sure the brain is dead, when the body is still alive. There are only a few mechanisms that will lead to this situation.
The most definite one is a severe head injury that leaves the body relatively intact. In such a case the brain swells and pressure inside the skull increases and closes the veins. The arteries continue to deliver more blood, dramatically increasing the pressure, until the arteries close as well. This effectively cuts of the brain's blood supply. In a short time the cells of the entire brain can die. In such a case, an angiogram will show no blood flow in the brain.
A severe stroke is another situation that may result in brain death. If the stroke causes enough brain swelling it can result in the same situation as described with the severe head injury. It is important to realize that most strokes do not cause enough swelling to entirely stop the blood flow to the brain. Therefore, only part of the brain dies.
The final situation that may result in brain death, while sparing the the body, results from CPR (cardio-pulmonary-resuscitation). The idea of CPR is to supply some blood flow to the brain, when the heart has suddenly stopped, until the heart is beating again. If CPR is started in a few minutes and the heart beat is restored within about eight minutes the brain may be spared. If it takes longer, the cells of the brain will begin to die. Because the organs of the body are less sensitive to lack of oxygen then the brain, it is possible that the brain could die and the body remain alive. This happens only in exceptional cases. Most often, if the brain won't survive the organs of the body will be damaged too. If the body does survive, at least, part of the brain likely survives too.
Use of the Term "Brain Death"
We have seen that it is possible for the brain to die and the body to remain alive. In medical terminology the term "brain death" is used to mean more then just death of the brain. It is used to mean death of the person when the body is still alive. I want to consider why "brain death" has come to be used in this way.
It is widely recognized that the main motivation for the development of this definition of death is the desire to have organs for transplant, as Dr John Doyle, of University of Toronto, in a paper supporting the diagnosis of brain death, admits.(23) Also, there is an interesting connection between the development of drugs, like cyclosporin, that prevent rejection of a transplanted organ, and the movement toward acceptance of "brain death."
It has also been suggested that the expense and emotional trauma of maintaining people on life support are the motivation for the development of brain death criteria. However, it is not likely that strict brain death criteria will solve this perceived problem of "keeping someone alive" in an intensive care unit. Many unconscious patients in intensive care units will not fit strict whole brain death criteria. Also, the problem of keeping someone alive on life support can be addressed without brain death criteria, as it is not always inappropriate to disconnect life support and leave the life of a person in God's hands.
Furthermore, consider who is promoting this significant change in the definition of death. It is the scientific community; primarily those interested in transplants. Christians have tended to place significant trust in the medical community, which has until recent years, at least paid lip service to a morality that considered God's standard. We are quickly losing this heritage. Consider Psalm 1 that says, "blessed is the man who walks not in the counsel of the ungodly." We must be careful not to naively accept the counsel the ungodly. Their counsel must be tried by the Word of God, by which we must "Test all things and hold fast to what is good." (1 Thessalonians 5:21 NKJV)
Proponents of organ donation claim that opportunity to save lives is being lost. They claim we are only harvesting a small number of the total available organs. They assert that if all potential donors consented to donate their organs, there would not be a problem with supply. Although I do not have numbers, I strongly suspect that there are not enough people who die in intensive care units on life support who meet the strict definition of brain death, in order to have enough donors to meet the demand, I am afraid that we will have to move in a direction of being less concerned about being sure the donor has actually died (Gen 9:5-6), and this is what is already happening.
What began as a definition of death, based on whole brain death criteria has been used somewhat loosely. For example, there is a 1987 study that demonstrated that many of the people in a position to apply the criteria did not know the criteria and applied it to test cases incorrectly.(24) Since then, the confusion has not settled. A recent review in Community Ethics critiques three papers to prove the assertion that "the topic of brain death" is far from being a "resolved" ethical issue.(25) I believe one of the reasons it is not resolved is because of the pressure from proponents of organ donation to define more people as potential donors.
There is pressure to move to a "higher-brain" rather than "whole brain" definition of brain death.(26) Dr. Howsepian, a medical doctor who delivered an argument against higher brain definitions of death, says,
There is a movement to try and redefine death, and make us think that somehow one can be dead even though one is moving, breathing, their heart's beating and there are brain waves are on the EEG...Robert Veatch has written extensively on this topic and is committed to try very hard to have people who are PVS or are demented in nursing homes, considered transplant donors.(27) (PVS = Pesistant Vegitative State. This is when a persons is believed to be conscious but appears to be unconscious.)
Another concern is that there is a movement to abolish the term "brain death."(28) The argument is that cardio-respiratory death is really only death after the brain dies. This is proved by the occasional success of CPR where the person's heart and breathing has stopped and is started again. It is suggested that this proves that "brain death" is the necessary ingredient, and that both the stiff body and the living body with a dead brain are equally dead. It is said that there are not two kinds of death so both should simply be called "death". Although there is an element of truth in this, there is a difference between a stiff, dead body with a dead brain and a living body with a dead brain. I hope to show you that a dead brain alone is not sufficient to define death of the person and the term "brain death" is not equal to "death".
A final alarming development is the use of "non-beating heart" donors. At first glance, this may appear similar to "clearly dead" donors. Remember that John Frame defined death in relation to the heart, the breathing and the brain. "Any of these may lose its function for a period of time and later be restored."(29) I have not been able to obtain a clear description of what happens to a non-beating heart donor, although I found several references to it in medical journals. A CBS 60 Minutes story on non-beating heart donors protocols from Ohio, and Wisconsin said,
In cases where a terminally ill or fatally wounded patient is on a respirator, and the decision has been made to end mechanical support of respiration, the family may elect to donate their loved ones' organs. In such cases, a pre-approved formal protocol will be followed to recover the organs once the patient is declared dead through cardiac criteria."(30)
I believe that non-beating heart donors are patients who are unconscious in an intensive care unit who do not meet brain death criteria, yet the family and doctors have decided to harvest the organs. The patient is taken to the operating room and the ventilator is shut off, or the drug support to the heart is stopped. The doctors wait until the heart stops beating then they start to retrieve the organs. In order for an organ to survive, the surgery needs to begin almost immediately after the heart has stopped. Has death occurred? Does the desire people have to find good in death, and the societie's pressure to donate organs lead to giving up on a person's life prematurely?
So, where do we draw the line as Christians? Can we accept "whole brain death" to be the same as death of the person? We are to do all things according to Scripture. Yet, the Bible does not talk of death in terms of the brain. What Scriptural teachings can direct us in finding the definition of death? The teaching I have found most useful considers the Scriptural definition of personhood.
There are two divergent definitions of personhood, described by B. Holly Vautier, in her paper, Definition of Death. First, the inclusive understanding of personhood is the tradition that acknowledges the human being as a single entity having both material body and an immaterial soul. This is founded on the Bible's record of creation when,
the Lord God formed man of the dust of the ground, and breathed into his nostrils the breath of life; and man became a living soul. (Genesis 2:7)
Every act of man is seen as an act of the whole man. It is not the soul but man that sins; it is not the body but man that dies; and it is not merely the soul, but man, body and soul, that is redeemed by Christ.(31)
That I with a body and soul, both in life and death, am not my own, but belong unto my saviour Jesus Christ.(32)
The other definition of personhood is the cognitive understanding of personhood, based on higher brain function. Being able to separate the living body from the person, as must be done to justify removing organs from questionably dead donors, is based on this exclusive, rather than an inclusive, understanding of personhood.
Holly Vautier writes,
Plato regards the body as evil--merely an impediment to the process of the soul. Descartes retains a mind/body dualism that reduces the status of the human body to that of a disposable piece of machinery. While the unified concept attributes goodness to the body, this view robs the body of all significance.(33)
She also states:
The prevailing moral ethos includes the value a culture places on individual human life. Where a strong Judeo-Christian ethic is evident, for example, life is regarded as a gift and a trust. It is seen as an intrinsic rather than merely an instrumental good...This sense of the sanctity or dignity of all human life has been influential in maintaining traditional western prohibitions against abortion, suicide, euthanasia, and hazardous medical experimentation on human subjects.
When an ethic which endorses life for all persons is replaced by an ethic of selective personhood, people are valued on conditional terms. Those who qualify for personhood (such as healthy, competent adults) retain their valued status in society. But those who fail to qualify for personhood (fetal life, disabled infants, incompetent adults, individuals who have lost their neocortical functions, for example) lose their status as valued members of the society. When loss of personhood is equated with worthlessness, depersonalization can too easily constitute a license to kill...Abortion is legal. The fiction of non-personhood, as urged by Marks, has reached even beyond Roe v Wade. It has extended into the special care nursery, where Drs Duff and Campbell have provided involuntary euthanasia for disabled newborns. these physicians have publicly justified allowing death as a "management option" when "the hope of meaningful personhood" is absent.(34)
As medical technology advances, there will be an increasing temptation to depersonalize individuals and groups under the aegis of social needs. How we resolve the issue of personhood will determine when our social obligations to individuals begin and end...The classification of human beings as non-persons opens the door to a utilitarian ethics in which medical treatment is granted or denied on the basis of quality of life or economic criteria. Since a non-personhood policy implies that individual life is dispensable, it could lead to the sanctioning of the procurement of donor organs from dying patients.(35)
We must uphold the intrinsic value of each person. Psalm 139 teaches us that each life, yet unformed in a mother's womb, is important to God. We were individual persons from conception. This was before our brain was formed. According to God, personhood on this earth begins at conception. The development of the physical presence of the brain is not what makes us important as individuals to God. If the development of the brain does not define personhood, is it right to claim that the death of the brain takes away our personhood? A true definition of personhood must include both body and soul. When the Preacher in Ecclesiastes describes death, he says, "then shall the dust return to the earth as it was: and the spirit shall return unto God who gave it" (Ecclesiastes 12:7, KJV). The body and the soul, that define the person, are not separated until death. Although there is separation after death, what happens to the body remains connected to the person.(36)
How, then, can we say that a person has died when it is still possible to keep the body from beginning to decay and from returning to the dust of the ground? I believe that as long as the life blood continues to flow in the body, keeping the body from the grave, we can not say that the soul has "returned unto God" (Hebrews 9:27).
When I began this research I wondered whether organ donation was permissible as long as it could be demonstrated that the entire brain was truly dead. After considering what I have learned, I must take a stand against using organs from persons until they are clearly dead, even though this means that many, so called, potentially useful organs will no longer be able to be harvested.
So far, we have considered clearly dead donors and questionable dead donors. We will now return to considering the different types of donors.
c. Living donors
Living donors are donors of organs or tissues the body can replace or do without. These include blood, bone marrow, bone, kidneys, and sperm and eggs. Sperm and eggs donation is an important topic that is beyond the scope of this paper.
First, we will consider kidney donations from living donors. God created our bodies with two kidneys. One kidney can usually be removed without an adverse impact on the donor's health. This allows the donor kidney to be obtained under optimum circumstances, while the recipient is being prepared to receive it. The amount of time the kidney is without blood supply can be kept short, and increase the possibility of a good results. The greater the genetic similarity between the donor and the recipient, the greater the rate of success and the less likely the new organ will be rejected. Therefore, the best living donors are often closely related to the recipient.
Bone donation from living donors is somewhat different from kidney donation. Bone is not taken from someone who is well. Usually, bone is left over from hip or knee surgery. The bone is tested, frozen and kept. Rejection of the bone is not a concern, as it is not the living cells that are needed but the calcium matrix on which the cells of the recipient can begin to grow new bone.
Bone marrow transplants and blood transfusions present little risk to the donor. (The main ethical issue here, revolves around the use of the "life blood" of one person in another. This issue is not covered by this paper)
Some Considerations in Regard to Donors
There are a some things a Christian should think about when transplants from living donors are considered. The principle of a Christian taking the risk and donating one of their kidneys can be supported. It is important to consider the likelihood of whether the kidney will survive and be of benefit to the recipient. Just as the deacons who help the needy, do not indiscriminately give these funds away, I think similar Biblical principles should be applied to the use of a donated kidney. We are to be good steward of all our gifts, that they honour Christ and promote the life and growth of the church.
We may want to ask ourselves some questions. Should the recipient not be concerned about where the organ came from? Should we not be concerned whether the organ or tissue was freely given or the result of coercion? With blood transfusions we expect the authorities to minimise the risk of using infected blood, but should we not concern ourselves with where the organ or tissue gift came from? Of course, we may view the donor's gift as a gift from God.
d. Fetal Tissue Donation
The donors, just mentioned, remained alive in the process of donating an organ. The next group of donors has been clearly and deliberately killed. I'm referring to the use of tissue or organs from aborted babies. The world calls it fetal cells and fetal tissue. They would like us to think that dissecting a person called a living fetus is less repulsive then dissecting apart a living unborn baby. For the last forty years there has been so called scientific research on living tissues from fetuses.(37) In North America, in Canada and United States, significant human fetal tissue research is taking place. The public became more aware of this about seven or eight years ago when the news reported that fetal brain cells were being experimentally implanted into the brains of people with Parkinson's disease. This is presented as good news, as potential cure for an terrible degenerative disease. Behind this "cloak of righteousness" experiments with living fetal bone marrow, pancreas, liver and nerve cells are being done in laboratories. Various fetal cells have been transplanted into various animals and the results studied. Numerous studies have also been done with transplants of fetal cells into humans. Experimental transplantation with fetal pancreas cells into people with diabetes is about twenty years old. These insulin producing cells have been reproduced in the laboratory. Similar studies have looked at fetal liver cells to replace bone marrow. And numerous studies have looked at implanting fetal brain cells in a variety of degenerative brain disorders.(38)
Originally, the fetal tissue was treated as being no different then other abandoned surgical waste material.(39) More recently, in the United States policies and laws have been passed defining when fetal tissues can be used. This has not stopped the experimentation. I believe that it has only resulted in giving the use of fetal tissue more credibility to the public.
It is said that abortions are happening anyway. If use of the tissue does not result in more abortions, it is not that bad, is it? The fact is that it is not done independent of abortions. One study was aimed at asking people who were seeking an abortion to sign up.(40) Supporters of fetal tissue transplantation believed that a decision to undergo a legal elective abortion can be separated from the subsequent use of the tissue. In 1988 most members of the NIH research Panel reviewing the issue reported that they regarded it highly unlikely that a woman would be encouraged to make a decision to abort based on knowledge that the fetus would be used for fetal tissue transplants. A 1995 study in the Canadian Medical Association Journal questioned 266 women randomly selected from a urban family practice. The study showed that the women who would consider an abortion thought they would be more likely to have one if they knew that fetus would be used for transplantation.(41)
Knowing this, how can the people who perform these experiments live with themselves? And how can the patients accept these treatments? Knowing this, should there not be a more significant outcry from Christians against such practices?
e. Stem Cells
There have been reports in the news recently about the possible use of stem cells to grow organ tissue or even organs to use for transplants. Most cells in our bodies contain all the information needed to describe everything in our body. Most of our cells have the bulk of the information turned off except what is needed to describe its own particular cell type. Therefore, liver cells remain liver cell; skin cells remain skin cells, etc. Stem cells are cells that are able to turn into a number of different cells. We have such cells in our bone marrow. They can replicate and turn into the many different types of cells found in our blood. If we can find a way to turn the right genes on and off, in theory, we could cause these stem cells to form into various kinds of cells in our body. The dream of scientists is to grow organs. If we could grow organs from our own cells we would not have to worry about rejection.
This sounds exciting, but the research is only in its infancy. I think it may result in some tissue types being grown, but to grow organs, which are made up of many different tissue types, presents many obstacles to overcome. I suspect that the obstacles are too great, but some amazing things have been accomplished in medical science.
As we consider the research, it is important to realize that a lot of stem cell research is done on fetal cells, rather than bone marrow stem cells. This is because the ultimate stem cells are the very early fetal cells that have not yet differentiated into the various cell types and organ types. It is much more likely that organs could be grown by cloning humans, using very early fetal cells, than by using more mature stem cells. The way some sheep have recently been cloned is by taking the DNA out of an adult sheep cell and replacing the DNA of a very early fetal sheep cell with the adult DNA. This is technically possible with humans. As mentioned already, such research with human fetal cells must be condemned.
f. Animal donors.
In light of the moral concerns associated with questionable dead donors and the use of fetal tissue, medical research is looking for different solutions. Animal donors would appear to be a good solution. The Bible tells us that man is given dominion over the animals and may use them to supply his needs. In Acts 10 it is recorded that God demonstrated to Peter that any of the animals of creation could be used for internal use. It says, "kill and Eat". Considered in association with the precept of Noah in Gen 9, which says, "But flesh with the life thereof, which is the blood thereof, shall ye not eat",(Genesis 9:4) this suggests that we should kill the animals before eating them. Another question is whether the use of live animal parts, especially with their blood in them, is honouring to God. Should we not be cautious in supporting the use of living animal organs without seriously considering this question before God?
An animal part that is commonly used in humans is pig heart valves. These are not kept alive and they have no blood supply. No drugs are needed to keep our bodies from rejecting them. The use of pig heart valves does not challenge the precepts of Noah.
Another item in the news is the development of pigs to act as donors. Leviticus 19:19 warns against the intermingling of distinct plant or animal kinds by cross breeding. This is part of the Mosaic law no longer in effect. But may it's principal not still be relevant? Man is also forbidden to have sexual relation with animals.(42) I believe this law primarily addresses the immoral desires of mens hearts, but it also affirms the creation order set by God, that each plant or animal reproduce after its kind. Generally transplantation of animal parts in humans would not involve cross breeding. So, I do not believe that this objection is valid.
The problems associated with using animal parts in humans, highlights how God has set the species apart. "Several formidable obstacles must all be overcome, including the effectiveness of the animal donor heart as a heart, matching the specific donor pig heart to a specific host human physiology, freedom of donor heart from carrying an animal-oriented disease into the human being, the surgery and its aftermath, hyperacute rejection and histocompatibility rejection."(43) If, ethically, animal organs can be used it will likely be years before this will be practical. If technology continues to advance in this direction it would make sense for the church to have studied the use of animal organs from an ethical point of view before it becomes a practical reality.
There is also the use of anencephalic babies as donors and the use of cord blood or placentas taken at the time of birth. We have not exhausted the various uses and experiments made with organs and tissues. But what has been presented will give plenty of food for thought.
This completes my presentation of the facts of organ donations and the concerns I have about the direction the medical and scientific world is headed. I trust you can appreciate why I am concerned and why we need to become knowledgeable about this topic. May God give us His wisdom and guidance if and when we should have to make decisions in regard to organ and tissue transplants. May he also grant us the strength to do what is right.
1. Matthew 23:25-27 - "you cleanse the outside of the cup and dish, but inside they are full of extortion and self-indulgence. Matthew 15:3-11 - "These people draw near to Me with their mouth, and honour Me with their lips, but their heart is far form Me. And in vain they worship Me, Teaching as doctrines the commandments of men."
2. 2Corinthians 5:16-21
3. 1Thessalonians 5:21 NKJV
4. Ephesians 5:10-11
5. 2Timothy 3:15-16
6. Revelation 12:9
7. Religious view of Organ/Tissue Donation and Transplantation. Though answers may vary from one denomination to another, research by agencies like the National Kidney Foundation have found that a majority of religions do support organ donation. A few of their finds were reported on the Internet at http://www.dnaz/OLD/pubedu/religion.html. They say, portions of these religions view were used with permission from Faith of our Patients prepared by committee on medicine and Religion, Texas Medical Association, Austin TX, 1979.
8. 1Corinthians 6
9. Peter 1
10. The reply of the Board of Evangelism and Social Action submitted at the 95th General Assembly of the Presbyterian Church in Canada, 1969, to Overture No. 12, 1968, Presbytery of Peterborough.
11. Summary in Journal Watch, April 28, 1979 of D. Wikler, A.J. Weisgard, "`Brain Death' and organ retrieval: a cross-sectional survey of knowledge and concepts among health professionals", JAMA, Apr 21, 1989. 261:2246.
12. Alan Joyce, "Truly Useful Literature: Brain-Death Dilemmas", Community Ethics, Volume 4, Number 1. (1996)
13. John E. Stronks, "The Slippery slope", Focus, Christian Medical Dental Society, 1997.
14. 2Corinthians 5:17, 1Corinthains 12:12-27
15. The Holy Spirit was poured out on his church, the body of Christ, at Pentecost. "And they were all filled with the Holy Spirit" Acts 2:4
16. Note on Acts 15:19 of the New Geneva Study Bible, 1995.
17. Matthew Henry's Commentary notes for Genesis 9:4
18. This part confuses me because the precepts of Noah say, "But flesh with the life thereof, which is the blood thereof, shall ye not eat." (Gen 9:4)
19. In February of this year the Stratford's news paper printed a story of arrests in New York of two people attempting to "sell" organs of prisoners set to be executed in China.
20. John M. Frame, Medical Ethics: Principles, Persons, and Problems, Presbyterian and Reformed Publishing Company, Phillipsburg, New Jersey, 1988, p. 58.
21. John M. Frame, p. 58.
22. "Guidelines for the diagnosis of brain death", Canadian Medical Association Journal, 1987; 136:200A.
"In 1968, following the publication of Harvard Criteria for the diagnosis of brain death, the CMA provided guidelines that were revised in 1974 and 1975. In 1976, guidelines were established in the United Kingdom, and in 1981 revised guidelines were published in the Journal of the American Medical Association."
23. D, John Doyle, MD PhD FRCPC, "The diagnosis of Brain Death: A Checklist Approach", Educational Synopses in Anesthesiology and Critical Care Medicine, The Online Journal of Anesthesiology, Vol2, No3, March 1995. (Dr. Doyle is associated with the University of Toronto.)
24. Summary in Journal Watch, April 28, 1989 of "`Brain death' and organ retrieval: a cross-sectional survey of knowledge and concepts among health professionals". Wikler D; Weisbard AJ, JAMA. 1989 Apr 21; 261:2246.
25. Alan Joyce, Managing Editor, "Truly Useful Literature: Brain-Death Dilemmas", Community Ethics, Volume 4, Number 1.
26. Alan Joyce, Managing Editor, "Truly Useful Literature: Brain-Death Dilemmas", Community Ethics, Volume 4, Number 1.
27. A. A. Howsepian, In defence of Whole-Brain Definitions of Death, The Center For Bioethics and Human Dignity, 2065 Half Day Road, Bannackburn, IL, 60016, USA. (this is an audio tape of a lecture)
28. Lance K. Stell, PhD, "Let's Abolish `Brain-Death'", Community Ethics, Volume 4, Number 1.
29. John M. Frame, p58.
30. Backgrounder, "Transplantation of Organs From Cardiac Death ("Non-Heartbeating Donors")", CBS 60 Minutes, April 9 1997. (from the internet)
31. Louis Berkhof, Systematic Theology, Grand Rapids; Eerdmans, 1939, p192.
32. Lord's Day one, The catechism in the back of The Psalter, WM. B. Eerdmans Publishing Company, Grand Rapids, Michigan, 1965.
33. B. Holly Vautier, "Definition of Death", in Dignity and Dying: a Christian Appraisal, edited by John Kilner et. al., William B. Eerdmans Publishing Co., Grand Rapids, Michigan. p 97.
34. B. Holly Vautier, p98-99.
35. B. Holly Vautier, p100.
37. D.E. Vawter, K.G. Gervais, "Ethical and policy in human fetal tissue transplants", Cell Transplantation, 4(5):479-82, 1995 Sept-Oct.
38. These facts were gathered through an internet search of medical journals, using Medline. A prominent journal covering these issues is Transplantation Proceedings.
39. G.E. Vawter, K.G. Gervais, "Ethical and policy in human fetal tissue transplants", Cell Transplantation, 4(5):479-82, 1995 Sept-Oct.
40. M. Westgren, et al., "Establishment of a tissue bank for fetal stem cell transplantation", Acta Obstetrica et Gynecologica Scandinavica, 73(5):385-8, 1994, May.
41. Douglas Martin et. al., "Fetal Tissue Transplantation and Abortion Decisions: A Survey of Urban Women", Canadian Medical Association journal, Sept 1, 1995, 153(5).
42. "The Ethics of Xeno grafting" extracts on the internet form a paper submitted to Nuffield Council on Bioethics in June 1995 from the Working Group on Genetic Engineering in Non-human Life Forms of the Society, Religion and Technology Project of the Church of Scotland and these are the Copyright of the authors, 1995. <http://webzonel.co.uk/www/strproject/xennuf03.htm>
43. "The Ethics of Xeno grafting" extracts on the internet form a paper submitted to Nuffield Council on Bioethics in June 1995 form the Working Group on Genetic Engineering in Non-human Life Forms of the Society, Religion and Technology Project of the Church of Scotland and these are the Copyright of the authors, 1995.