Arguments over when someone may be declared dead paradoxically elicit much less violence and recriminations than disputes over when a collection of human tissues should be declared a ‘person.’ Some people still abide by the ‘heartbeat’ rule, which defines a living person as a human, whether he or she be in development or in decline, with evidence of a heartbeat. In the human embryo, what is defined as ‘a heart’ is vastly different from what it develops into, but calling something that eventually develops in the chest area and can be observed pulsating ‘a heart’ is simple and unambiguous. At the other end of the spectrum, declaring someone who does not have a heartbeat as dead is equally simple and unsubtle. Unfortunately, this focus on the heart as a determinant of what constitutes living or dead, at least as it relates to humans, became unreliable and obsolete more than sixty years ago.
People with excellent, reliably beating hearts are declared ‘dead’ on a routine basis. Their hearts may be harvested and relocated to the chest of an individual with a failing heart, and no one is charged with murder or even assault. What justifies the removal of the heart is the status of the brain, not the status of the heart. Once an individual is declared ‘brain dead,’ his or her organs can be legally collected and given to other people. What constitutes ‘brain dead’ has been argued by well-intentioned people for several decades, but there is currently a national consensus, at least amongst neurologists, transplant surgeons, and legitimate transplant facilitators.
Although brain function is a central issue in determining when a human body is dead, it has gained little or no traction in the very heated and seemingly endless debate over when an embryo or a fetus deserves being designated ‘a person.’ Many of our fellow Americans support the view that a fertilized human egg, a primordial cell with 23 chromosomes, deserves the rights and protection mandated for a fully developed human being. Others have decided that the fetus that has had 25 or 26 weeks to develop is sufficiently viable, even though it has little more than the blueprint for a brain and will need many weeks or months of complex support, to be considered a ‘citizen.’ Whether or not that fertilized egg is awash with genetic defects or that 26 week old fetus has little or no brain [anencephaly] does not enter the discussion.
Seventy years ago, deciding what is living and what is dead, when life begins and when it ends was all much simpler. Heart and other organ transplants were impractical. The man or woman with a heart that failed would die as soon as that heart stopped beating. The fetus that arrived prematurely at 25 weeks would also routinely die from perinatal complications or survive briefly with extensive brain and other organ damage. The fertilized egg with numerous genetic defects rarely led to a viable birth, and anencephalic children were equally unlikely to survive. Advances in medical science, fetal support, transplant techniques, etc. have changed the inevitables to not so inevitable. Our cleverness has given rise to our quandary.
The pressure to obtain organs for transplantation has led to mistakes. The demand for organs is so intense now that rules get bent and absolutes are redefined. I was consulted in a case in which a man showed no neurologic signs of life but had excellent heart and kidney function. How he arrived at this moribund state was a mystery; but his blood cultures were negative, and his blood chemistries appeared to be normal. He had no known relatives to consult, and his organs were deemed high value. He met all the criteria as an organ donor accepted at that time, save one: no one could explain why he appeared to be brain dead. The neurology consultants were criticized for not signing off to allow the organ harvesting, but one person did believe they did the right thing: it was the patient. He emerged from his coma in a few days, at about the same time a misplaced chemistry report came back showing that he had toxic levels of magnesium in his blood. He had mistakenly swallowed Epsom salts [magnesium sulfate] that he had been given to soak his sore ankles.
Complex medical issues are being decided in legislatures, rather than in doctor’s offices and living rooms. Our politicians are intent on satisfying special interest groups without first investigating the issues they are drafting laws regarding. The former President [DJT] has demonstrated his support for abortion opponents while simultaneously claiming support for in-vitro fertilization [IVF]. He is obviously unaware of the need to discard embryos (de facto abortion) as an inevitable consequence of IVF. States banning abortions are requiring women carrying fetuses with lethal gene defects or severe brain abnormalities to risk their own lives or fertility by continuing their pregnancies to term or to miscarriage. This is heartless and nonsensical.
Dr. Lechtenberg is an Easton resident who graduated from Tufts University and Tufts Medical School in Massachusetts and subsequently trained at The Mount Sinai Hospital and Columbia-Presbyterian Medical Center in Manhattan. He worked as a neurologist at several New York Hospitals, including Kings County and The Long Island College Hospital, while maintaining a private practice, teaching at SUNY Downstate Medical School, and publishing 15 books on a variety of medical topics. He worked in drug development in the U.S., as well as in England, Germany, and France.
