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Ethics Debate In Germany: Are The Brain Dead Dead Enough For Organ Removal?

Is it OK for doctors to remove the organs of people who are brain dead but whose bodies still function metabolically? The German National Ethics Council grappled with the issue this week. One panelist supported the practice, saying the brain dead &quo

Matthias Kamann

BERLIN -- During discussions about organ donation on Thursday at Germany's federal parliament, the Bundestag, Green politician Jürgen Trittin shared a story about the death of someone he was close to. The woman died in a cycling accident, and it was up to Trittin to convey the news to her family. As difficult as that task was, it would have been worse, he said, if he'd also been responsible for deciding whether to donate his friend's organs.

"When I think that I would have been in the position of trying to interpret what she would have wanted…" he said.

The experience made Trittin realize first-hand just how important it is that people write an unmistakably clear statement about whether they want their organs donated when they die. Otherwise, a person's loved ones must end up making the agonizing decision.

Trittin's tale makes it clear there's more to the issue than just campaigns urging more people to donate. Indeed, there are a lot of delicate questions to be considered, such as how to find a decent compromise between the needs of loved ones, who want time to say goodbye, and the quick surgical action required to cull organs. Another example: intensive medicine is generally recommended for dying patients who plan to have their organs donated, and yet sometimes people prefer not to receive intensive care in their final days and hours.

And then there's the question of how to handle organ donation involving people who are deemed brain dead. The crux of the matter is this: Are the brain dead in fact dead?

"Decapitated from the inside"

The German National Ethics Council grappled with just that question in Berlin on Wednesday in a panel discussion attended by an audience of some 400. According to American neurologist Alan Shewmon, the brain dead are not dead. While it's true that they have complete loss of brain function, brain dead people continue, nevertheless, to function metabolically, he explained. Wounds heal. Brain dead children continue to develop to sexual maturity. A brain dead pregnant woman carried her living baby to term. Some brain dead patients require less intensive care than patients whose vitality nobody would question. "The brain dead are unconscious – but they are alive," Shewmon said.

No, countered Munich neurologist Stefanie Förderreuther: they are dead. Förderreuther compared a brain dead patient to somebody who had "been decapitated from the inside." The damaged brains of patients in a waking coma still show signs of activity. Not so the brains of brain dead patients. That some organs or hormonal activity continued to function was mainly due to support systems in intensive care. That kind of functioning, however, doesn't turn patients back into people "aware in both body and mind." Only the brain could do that. Ergo it was admissible to remove organs from the brain dead.

Most of the panel speakers shared Dr. Förderreuther's position. Moral theologian Eberhard Schockenhoff, for whom, as a Catholic, the protection of life is a particular duty, insisted on the fact that the brain dead are dead because they are no longer organically autonomous people, "body and soul."

That Schockenhoff and others placed so much importance on brain activity in the expression of human personality stood in stark juxtaposition to Shewmon's position, who spoke of life as a thermodynamic phenomenon.

Philosopher Ralf Stoecker, however, pointed out that we nevertheless handle the brain dead differently from the dead. The former may not be used for dissection by medical students, for example, because "they're personally dead, but they're otherwise alive," he said. And yet Stoecker supports organ removal from the brain dead because "they can't feel joy or pain, and you aren't taking any future away from them -- they are in a sphere that knows no time."

The controversy over when dead means dead is unlikely to be taken further in the discussion about organ donation in Germany. But the general debate about what constitutes death in the era of high performance medicine will go on. Finding solutions, according to philosopher Volker Gerhardt, will become ever more difficult because we've manipulated nature so much we don't have any fixed reference points any more. "Falling back on so-called ‘nature" is no longer an option," he said.

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