Eliminating Death

Organs for transplantation have been retrieved from both living and dead donors. Living donors have given a kidney, a lobe of liver, a lobe of lung, a portion of the pancreas, and a portion of intestine. In 2001, for the first time, the number of living kidney donors exceeded the number of cadaveric donors (United Network for Organ Sharing n.d.). The heart and the entire liver can be taken only from dead donors because removal of these vital organs would kill the patient. Both kidneys cannot be removed from a living donor because that would cause kidney failure and mandate dialysis. Organ retrieval for certain donations requires a prior declaration of death.

Elysa R. Koppelman (2003) wants to jettison the requirement that patients be declared dead prior to the retrieval of vital organs, because there is no "consensus definition of death." Koppelman correctly notes that controversy exists over the definition of death. Three major reasons explain this controversy. Death is a complex human construct that is not easily linked to a simply measured empirical parameter, as is height or weight. In Non-Heart-Beating organ transplantation, death is not simply defined but the contentious step of identifying when it first arrives has been taken. Defining death using neurological criteria (whole brain death), the traditional, comfortably accepted criteria of the irreversible cessation of circulation and respiration cannot be employed, because patients are attached to mechanical ventilators that sustain breathing. A substantial book filled with various versions of the definition of death buttresses Koppelman's contention that death is a controversial concept (Youngner, Arnold, and Schapiro 1999).

If we acknowledge that definitions of death used for transplantation are ambiguous, flawed, or manipulated it doesn't necessarily follow that death and the dead donor rule should be abandoned. The concept of death might not be absolutely impervious to criticism, but it should not be eliminated unless there is a preferable alternative. If vital organs may no longer be retrieved when the corporeal body is in a state called death, then when may they be retrieved? What replaces death? Has Koppelman defined and developed an alternate state of being for the body in which vital organs may be removed? Has she developed a definition, criteria, and practically applicable tests that define this state? And will she achieve the consensus she claims is lacking for death?

Koppelman's replacement for death lies "between life and death." This is a puzzling location because an organism can be either alive or dead; there is nothing between those two states. Patients in a deep coma or a persistent vegetative state are nonetheless alive. Koppelman doesn't give her intermediate state a consistent name but refers to it as a "slippery state" and as a "suspended state" and sometimes a "permanent vegetative state." (I assume that by "permanent vegetative state" she means patients in a persistent vegetative state who will never recover—a determination that cannot always be made with certainty.)

Koppelman never precisely describes her "slippery" or "suspended" state. She doesn't provide a clear conceptual definition beyond the puzzling, "being in such a state is like being in no state at all." She doesn't tell us what diagnostic tests define this state and she doesn't tell us whether we could end up removing the heart from someone who might otherwise have recovered. A clinician at the bedside who wanted to determine whether a person was in Koppelman's "slippery" or "suspended" state would be bewildered. He or she would not know what clinical parameters were relevant and would not have the slightest idea how to confirm the diagnosis.

Even those who quarrel with the notion of brain death must admire the comprehensive development, clarity, precision, and practical applicability of the concept. Koppelman could use as a model the approach taken to define as brain death. Death is first defined as "the permanent cessation of the critical functions of the organism as a whole." The criterion for death is "the permanent cessation of clinical...