During my A-level years I remember being handed a leaflet on organ donation. At the time, I was not a Christian and ideas about death and what would happen to my body at that dim distant point in the future were not my primary concern! Feeling this to be a worthy cause, I filled out a donor card...and then promptly lost it. After reading about the current shortage of organ donors earlier this year, I felt freshly convicted and resolved to take a closer look at the issues involved.

For most Christians, transplanting organs from a dead person presents no ethical problem in itself, as has been discussed in previous Nucleus articles.[1],[2],[3] Giving of ourselves is very much part of Christian ethics and follows Christ's example (Jn 15:13, Rom 5:8, Gal 4:15). However, the recent drive to increase the availability of organs leaves me with two questions.

1. Have the donors really consented?

At present, a dead person's organs can only be transplanted with prior consent, for example in the form of a donor card. But in December last year, the BMA approved plans that would make the organs of all dead people available, unless they had specifically registered an objection.[4]

This 'opt-out' system has greatly increased the number of organs available for transplant in other European countries. But is it ethical? Presumed consent appears to me to be a way of making the doctor's job easier, waiving the need for patients to be given adequate information upon which they can make informed consent.

Doctors might no longer strive to find out what patients want, the desires of the deceased could be ignored and vulnerable groups in society (eg ethnic minorities and mentally incompetent individuals) could be subject to exploitation. It is important to find out what people's wishes are and to respect them. This means being open, truthful and honest (Phil 4:8) so that we may have a clear conscience and patients may feel they are able to trust us.

2. Are donors really dead?

In the past patients were deemed dead if they had no respiration and no heartbeat. The term 'brainstem death' arose because some 'clinically dead' patients can now be resuscitated and kept alive on ventilators. As a result, diagnostic criteria for brainstem death were developed to identify those patients with respiratory failure who could be justifiably 'switched off'.

Then in 1979, a memorandum from the Royal Colleges and their faculties determined that brainstem dead patients were really dead. Organs could now be taken from these ventilated patients for transplant and this opened up the possibility of electively ventilating potential donors. Previously, the only organs that could be transplanted were those surviving for a period after death (eg kidney, cornea). But since this ruling heart, lung, liver and pancreas transplants have been possible; the organs being removed from donors before the ventilator is switched off.

Are brainstem dead patients really dead? David Hill, a consultant anaesthetist writing in Triple Helix[5] thinks not. Evidence suggests that there is residual brain activity in higher centres of the brain, so consciousness cannot be excluded. Furthermore, when the donor undergoes operation, a number of physiological responses occur (eg rises in pulse and blood pressure) which cannot simply be attributed to spinal reflexes below a dead brainstem.

Just because someone is going to die, I do not feel this means we have the right to say they are dead. There is a world of difference between being dead and being as good as dead, and we seem to be deliberately concealing this from would-be donors and their relatives.

Whether or not it is possible to justify taking organs from brainstem dead patients if they are recognised as living is an issue on its own. But it is the lack of openness and honesty that I am concerned about. As with presumed consent, certain groups of people, such as those with PVS, head injury and dementia, who rely heavily on support, may end up being exploited. To allow organ transplants from these patients would be wrong and must be resisted. In explaining matters of death to people, I believe it is our duty as doctors to be truthful and honest (Ps 15:1-3, Pr 12:22, Zc 8:16, Mt 5:37).

Conclusion

Organ transplantation is an acceptable practice for most Christians and in my view should be promoted, but there is a need for greater openness and honesty. Efforts should be made to educate people about this subject and find out what they want, rather than imposing on them what they may never have wanted. For me there is a clear distinction between people being nearly dead and really dead, and I believe doctors should be willing to admit this openly and explain it to potential donors.