| Home Original contribution to the Draft from David Hill and David W Evans Dr David Hill's response to the Draft for Consultation for A CODE OF PRACTICE FOR THE DIAGNOSIS AND CERTIFICATION OF DEATH The Old Post House Eltisley Huntingdon Cambridgeshire PE19 6TG Dr Peter Simpson President The Royal College of Anaesthetists 48-49 Russell Square LONDON WC1B 4JY 10th June 2006 Dear Peter, Working Party on Brainstem Death It was na�ve, I suppose, to think that the Working Party would come up with anything other than this justification of the status quo. It is astonishing, however, that there should be not even a nod towards the substantial body of reputable international opinion questioning the ethics and science of our present methods of certifying death for transplant purposes. A considerable body of such evidence and opinion, peer reviewed and extensively referenced, was presented through you to the Working Party, none of whom apparently regarded it as of significance. This revision, to be presented to the Academy of Medical Royal Colleges and the Department of Health (who are mainly non-medical) and marked �Draft for Consultation�, omits all reference to contrary views. If no discussion is to be allowed in the consultation process, it is hard to see how they, let alone the public who are most affected, can be expected to make a valid judgement. The Working Party�s concern under section 1, p.7 that �Relatives, partners and carers of the patient should be given explanation of the investigations undertaken AND OF THEIR INTERPRETATION� (my emphasis) does not seem to extend to raising any contrary views. I suggest that no reputable refereed journal would accept such a totally biased and inadequately referenced �consultation document� as this. The �wider professional and lay interests� (p.6) do not apparently include any of the doctors, nurses, philosophers or ethicists who question or doubt the validity of the procedures. It is frankly misleading to claim that they �have drawn upon much of the comment received over the existing guidelines�, when contrary views from responsible quarters are suppressed. The Working Group attempts �to completely separate the diagnosis and certification of death from anything to do with the issues surrounding organ donation and transplantation� (para. 1, p.6). If this were true, there would be no need to alter the original 1976 recommendations which provided for conditions when the ventilator could be turned off and the patient be allowed to die. All the subsequent changes are devised to declare death BEFORE the ventilator is removed, in order to obtain viable organs for transplantation. It was the perceived need for organs for transplantation that motivated the original Conference of Medical Royal Colleges and their Faculties in the United Kingdom report of 1976 to be changed. The 1976 report stated the conditions under which the ventilator could be turned off in the secure knowledge that the patient WOULD NOT RECOVER, NOT that the patient was already dead. All the subsequent changes, including those of this Working Party, are required ONLY in order to obtain viable organs for transplantation. The 1979 Memorandum changed the 1976 paper by saying that, the same clinical tests that determined a fatal prognosis, could be used to pronounce that death had already occurred, because by then ALL (my emphasis) functions of the brain had permanently ceased. �Brain death� was later modified to �brainstem death� on the basis of Pallis�s idiosyncratic assertion that the essence of human life is contained in a few cubic centimetres of tissue in the brain stem, even though it is known that residual activity in the higher brain may persist and many, if not all, integrated physiological functions continue. Pallis himself wrote that whole brain death in that sense is a fiction. It is deeply disturbing that the Working Party propose to retain Pallis�s definition of death � �the irreversible loss of the capacity for consciousness, combined with irreversible loss of the capacity to breathe� � a utilitarian ex cathedra pronouncement without scientific or philosophical justification. Further obscure and manipulative definitions of death occur in the Draft Consultation Section 2, Appendix 6 referring to �patients certified dead by neurological testing of brain stem reflexes� and in appendix 9 the term �brainstem death(d)� is replaced by �death(d) following cessation of brain stem function�. This is hardly conducive to a clear understanding of �death� or necessary, if as claimed in the Working Party draft, there is no eye on obtaining viable organs for transplantation. Paragraph 1 of the Introduction claims that use of the brain stem tests can make us �confident about the professional and legal acceptability of discontinuing interventions that merely serve to prolong somatic function�. However, when organs are to be taken, interventions ARE continued merely serving to prolong somatic function. In Paragraph 2, the obsession with brain stem death leads to the statement that, following cardio-respiratory death, �The doctor has to be certain that there has been irreversible damage to the vital centres in the brain stem�. The implication is that in all cases of cardio-respiratory death (the vast majority of deaths) the brain stem tests must be carried out before certifying death. This is clearly nonsense. Paragraph 3, p.9 continues the clumsy attempt to link cardio-respiratory death with brainstem activity by implying that the historic time-honoured ways of recognising cardio-respiratory death are somehow deficient and that brainstem tests would be better. The Working Party�s attempt to separate the certifying of death and organ harvesting is contrived and does not work. It is significant that the two references (7 & 8 in Paragraph 3, p.9) giving advice to wait 5 minutes after cardio-pulmonary arrest before certifying death are both SPECIFICALLY CONCERNED with obtaining viable organs from patients referred to as �controlled� non-heart-beating donors. If organs were not sought, no time limit would be needed or, if it were, it could be a great deal longer than 5 minutes. The statement in Paragraph 3, p.8 that death is a process rather than an event is not supportable. It is, of course, DYING that is the process and DEATH that is the event, or better, the STATE described in the document when death can be certified. It is intellectually interesting to consider what is the exact point at which death occurs, but this is of no practical importance where organ harvesting is not concerned. As a houseman, the call at night by nurses to certify a death was the one occasion when time was not of the essence. Paragraph 4 on p.10 contains a number of very questionable statements. It is regularly observed that, unless suppressed by anaesthesia, surgery for organ harvesting in those declared brainstem dead stimulates severe hypertension and tachycardia. The claim that this is not mediated through the medulla is an assumption without evidence and is contrary to the usual principle that primary mechanisms are invoked unless proved otherwise. The similarity of response to that of any other intact patients would indicate medullary control. The constantly repeated statement that the heart will inevitably stop beating �shortly� or �within a short period� (paragraph 6, p. 13) is at odds even with the document�s statement in paragraph 6.4 on p.17 that heartbeat may continue for a few weeks. It is incorrect and misleading to say that for a patient in a coma �respiration and circulation can be artificially maintained�. The need is for mechanical ventilation. Respiration (the exchange of gases) continues normally, as does the spontaneous and unassisted heart beat and circulation. �The appropriate course of action is then to withdraw mechanical respiratory support� (and one might add �and allow the patient to die�) is correct, but at odds with the practice when organs are sought and such life support is then continued. The ends then are used to justify the means and imposing �a pointless and distressing vigil� on family and friends is apparently justified. Paragraph 6 is extraordinarily paternalistic and unscientific in simply dismissing without any evidence or discussion as �irrelevant� residual brain stem and higher brain activity, the spontaneous and responsive movements, the retention of normal physiological activity and the lack of the usual signs of death. Irrelevant to whom? one might ask. To the Working Party perhaps but not perhaps to the reported 40-50% of relatives who refuse consent for organ harvesting but nevertheless agree to life support being discontinued and the relative be allowed to die. I have not included references to these comments as they are contained in the previous papers sent to you and the Working Party members. CONCLUSION There are other criticisms but, in summary, it is deeply distressing that this Draft Consultation is so autocratic; that it contains so many flaws; that minds are apparently closed to the discussion that has taken place over the last 25 years; that the quite obvious link between the need for invoking brain stem death and the harvesting of viable vital organs from a living body is so strenuously denied. All is not necessarily lost if it can be agreed that, as the evidence indicates and recent papers have proposed, the brain stem tests are adequate to establish the prognosis of an inevitable death, which was their original purpose in 1976. Then the alternatives are for relatives to give permission to discontinue life support and allow the patient to die; or to give permission for a controlled withdrawal of life support and (with fully informed consent and guaranteed anaesthesia) the harvesting of organs. If this were agreed, one could either (with further informed consent) wait for cardio-pulmonary death or proceed with surgery in the knowledge that this will finally terminate the patient�s life. This would probably require further legislation and would raise further questions but would have the virtues of clarity and honesty. I regard this as an open rather than a personal letter, and am copying it initially to each of the members of the Working Party and to other concerned colleagues and friends. With kind regards, Yours sincerely, Dr David J Hill Copies to: Professor Len Doyal Dr Nick Kane Miss Sue Falvey Dr Colin Kennedy Mrs Jean Gaffin Professor Sir Ian Kennedy Dr Robin Howard Dr Steven Kerr Dr Alex Marara Me Keith Rolles Professor J D Pickard Dr Alasdair Short Dr David W Evans The Draft For Consultation Paper Dr David Evans' and Dr David Hill's original contribution |