EXPERIMENTAL AND CLINICAL TRANSPLANTATION

The definition of death remains unresolved. To define death, one has to define the characteristics of a living person and to confirm whether an individual with brain death fulfils any of these characteristics. Although the concept of irreversible cessation of brain function is clear, controversy remains on the treatment of individuals with brain death and beating hearts. An individual with brain death but a beating heart is not breathing on his own and is dependent on medications and machines to maintain respiration, heartbeat, and blood pressure. Muslim scholars remain divided over the issue of whether death also means irreversible cessation of brain function. Questions remain on when it is permissible to remove vital organs for organ transplant. Groups have advocated for uniformity in law and medical practice on the definition of brain death.

Key words : Brain death, Deceased donor, Organ transplantation, Religious views

Death is not only a medical diagnosis but also a philosophical, legal, and religious diagnosis. Once death is announced, many legal and religious consequences will follow, especially when applying rules of inheritance and marriage.

For thousands of years, the assumption has been that life is in the heart and breath and that death can only be announced once breathing and heart beats stop.¹ This definition was challenged with development of technology to help with breathing in patients. Initially with the invention of the iron lung, in 1927, to save patients with polio disease and paralysis of respiratory muscles. In the 1950s, positive pressure ventilators came to be used in intensive care units established to treat patients needing assisted respiration.¹ Artificial ventilation has saved many patients with coma due to brain injuries following road traffic and cerebrovascular accidents.

However, the use of advanced life support machines in the 1960s created ambiguity in determining death.² Some patients in deep coma with catastrophic brain injury were maintained on machines, even with knowledge that coma was irreversible and that the patient would not recover.

In the same period, organ transplantation from deceased donors began, with the first liver transplant by Thomas Starzl in 1963, first lung transplant by James Hardy in the same year, and first heart transplant by Christian Barnard in 1967. Organs were retrieved after life support machines were stopped and a few minutes after cessation of heart beats had passed.³

In 1968, a Harvard ad hoc committee was formed to examine the definition of death in view of observations made in cases of irreversible coma. The committee was formed of 13 members, which included 10 physicians. The remaining 3 members of the committee were a theologian, a law professor, and a science historian. The title of the report after publication was "A definition of irreversible coma,” which was different from the intention to define death.⁴ Not everyone agreed that patients with irreversible coma were brain dead. However, the committee agreed that a heart beat does not necessarily mean that a person is alive. It is interesting that Peter Murray, a famous transplant surgeon who performed the first successful kidney transplant, was among the physicians. To many, this indicated that death was redefined for the benefit of transplant specialists, who preferred heart beating deceased donors, to avoid warm ischemia of organs. However, although transplant specialists had a vested interest in revising the definition of death, the idea had been raised as early as 1939, when Crafoord defined death as cessation of blood flow to the brain.⁵ In 1959, Mollaret and Goulon described the condition of patients on ventilators with deep irreversible coma, apnea with no reflexes, low blood pressure, and absent electroencephalogram activity as being beyond coma (coma dépassé). In addition, 5 years before the Harvard criteria appeared, Guy Alexander, a Belgian surgeon, conducted the first transplant in his country from a heart beating deceased donor.⁶

The concept of being dead despite having a heart beat did not initially get wide acceptance, even from transplant professionals. The famous pioneer of liver transplantation, Thomas Starzl, said, "I doubt if any member of our transplantation team could accept a person as being dead as long as there was a heartbeat.”⁷ He was wrong, and the concept received wide acceptance, initially in the United States and then all over the world.

Despite its wide acceptance, some controversies have remained around the concept of brain death. Not all states in the United States have adopted the definition in its laws and regulations. Thus, a dead person in one state can be legally alive if moved to a neighboring state.⁷ It was soon discovered that the Harvard criteria of whole brain death were not valid, since some functions of brain are retained, such as hypothalamic and pituitary functions.⁸ More than 50 years later, the definition of death is still unresolved. The irreversible cessation of brain functions is a clear fact, but controversy remains on the treatment of individuals with brain deaths and beating hearts. The decision on continuing expensive treatment for such individuals is complex, as such individuals may occupy beds needed for other patients but treatment may be futile.

Definition of a Living Person
To define death, one has to define the characteristics of a living person and to confirm whether an individual with brain death fulfils any of these characteristics. A living person has a conscious life, is unique with personality, and has capacity for remembering, judging, reasoning, and acting. A living person enjoys life and reacts to circumstances.⁹ An individual with brain death has none of these characteristics. In addition, an individual with brain death is not breathing on their own and is dependent on medications and machines to maintain respiration, heartbeat, and blood pressure to keep organs functioning.

Acceptance of Brain Death by Muslim Scholars
There is no definition of death in the Quran or the traditions of the prophet, and Muslims traditionally consider cessation of breathing and heartbeat as end of life.¹⁰ Brain death was initially rejected by majority of Muslem religious scholars; however, in 1986, in a meeting in Jordan, brain death was discussed in a joint meeting of religious scholars and Muslim physicians. At the end of the meeting, participants agreed that death occurs either by irreversible cessation of heartbeat or irreversible cessation of brain functions.¹¹ However, over the next many years many new scholars challenged the definition of brain death. Muslim scholars remain divided over this issue.

Irreversible Vegetative Status
Comatose patients who have major brain injuries but have intact brain stem and breath on their own are not considered by medical community as dead. They may remain in an irreversible vegetative status for years without any hope of recovery and most will die of infections, especially chest infections. However, they do not posses any of the characteristics of living individuals. Muslim scholars who support the concept of brain death and encourage organ donation from heart beating deceased donors as an honorable act have special views on individuals with irreversible vegetative status. In a meeting held in Kuwait, the late Sheikh Yousef Alqaradhawi, one of the most prominent religious scholars in the Arab world, in the last forthy years, was asked about organ retrieval from such cases. He pointed out that this is permissible since such an individual does not have a meaningful life and cannot be described as a living being.

Another famous scholar and Chair of Islamic studies at George Mason University (Fairfax, VA, USA), Professor Abdul Aziz Sachedina, stated, "Life in Muslim culture has a set of criteria which must be fulfilled in order for the patients, their families, and society in general to regard a person living.” He considers treatment of any case with severe brain damage, in a vegetative status, to be futile and will lead to further suffering of the patient and those related to the patient in society, in addition to the costs of prolonging such life for the entire society. He has stated that Muslim jurists should allow discontinuation of treating such cases. Furthermore, he stated that it is degrading to intervene medically in nature's course toward an imminent death.¹²

The Dynamic Soul
According to the Quran (verse 39:42), the soul departs from the body not only at death but also during sleep. When death occurs, the soul does not return. This indicates that the soul has departed whenever a person is in coma.

The Controversy Continues
There seem to be a wide range of opinions regarding the definition of death, from the traditional definition based on cardiorespiratory function to the definition based on neurological criteria of brain death, with additional opinions on individuals in a vegetative status who lack the characteristics of a living person and cannot be considered being alive even if they breathe spontaneously.

Questions remain on when it is permissible to remove vital organs for organ transplant; if transplant is not planned, when should "life”-sustaining treatment for severely comatose patients be stopped and is family consent necessary before stopping treatment?

In December 2008, the President's Council on Bioethics presented a white paper entitled "Controversies in the Determination of Death” to the President of the United States. The paper presented the ethical questions on neurological standards, such as the clinical determination of whole brain death, and requested uniformity in law and medical practice nationwide.¹³

Among the current dispute is the ability of family to refuse brain death tests and possibility of clinical error in diagnosis. Some question the irreversibility of loss of function. Death remains a philosophical as well as a medical diagnosis. Of note, although most Muslim scholars still do not accept brain death, have gone beyond brain death to even consider individuals with vegetative status as not being alive. The controversy continues.

Volume: 22 Issue: 4 April 2024 - Supplement - 4

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