"I am always amazed by the will our patients have to survive, almost at any cost". So said David White a director of Imutran, the company involved in developing genetically modified pigs for use as an organ supply in xenotransplants (animal to human transplants). I was expressing my doubt about ever wanting to undergo an organ transplant if faced with the possibility. But it has to be admitted, that unconscious urge we call the 'survival instinct' must run very deep, for instance in crowd disasters when people clamber to safety over the dying. Just as physicists have wondered whether human life would exist if just one of the constants of physics were altered by a tiny amount, likewise might we wonder whether it would exist if the desire for life were diminished even slightly. Given this instinct, can any of us predict what we might do if offered an organ transplant? Perhaps not, but we can make ourselves aware of what might be involved so that any future decision has the chance of being informed by moral intuition rather than by instinct. To do this as freely as possible would seem to require thinking over the matter sooner rather than later when our consciousness and thus our freedom are partially compromised by illness and pain.

History

Liquid tissue 'transplants' have long been routine. A rational basis for blood donor/recipient matching came at the turn of the century when the blood groups were discovered and was further refined in 1939 by taking into account the Rhesus factors. Skin transplantation was used more than 2,000 years ago but became part of western medicine only in the last century. This article is concerned with solid organ transplantation which did not develop until this century. Like successful blood transfusion, organ transplant depends on tissue-typing and matching, the immunological basis of which was not discovered until the 1940s. The world's first successful kidney transplant was in 1954 as a live donation from an identical twin. Liver transplants began in the early 60s and in 1967 Christian Barnard amazed the world with his first human heart transplant. Only in the 1980s, with progress in understanding the immune system and the availability of new drugs to prevent rejection, did organ transplant become a potentially routine form of therapy in modern medicine.

Statistics

I say only 'potentially' routine because transplant surgery is severely limited by shortages of organs. Recent UK annual figures^1,2 for the waiting list and actual transplants of some organs are as follows:

The list of transplantable organs is getting longer. Organs and tissues from one donor, William Norwood, were used to help 52 other people. According to BODY², 1500-2000 people, mainly kidney patients, die each year in the UK while waiting for organs. It is these people one might wish to keep in mind when considering whether to register oneself as an organ donor and carry a donor card. (see below) Whilst the above figures show that most people are not very likely even over their whole lifetimes to encounter someone needing or having received a transplant, the issue affects everybody precisely because everybody is a potential organ donor, even nowadays the quite elderly.

Meyer suggests that a strong push for more transplants comes from commercial interests.³ These could range from drug companies to medical suppliers, to even the medical profession itself. Every shortage has a corresponding need. But who creates the need for transplants? Is it real? Advertising uncovers needs or desires which people hitherto did not realise they had. Patient interest groups generate the hype that spurs the fundraising. Transplant surgeons help such groups. Whose need is the greater, surgeon or patient?

There also exists a worldwide trade in human organs which some regard as a reintroduction of slavery by the back door.⁴ Legislation was passed some time ago to ensure that the UK is not part of it.

Organ failure

To say that a person contemplating an organ transplant is at death's door is rarely an exaggeration. Wolfgang Bünnagel, a heart transplant survivor who was initially against it on principle, has given a vivid account of how the operation greatly extended and dramatically improved his life.⁵ Whereas his illness was not entirely within his own control if at all, a large group of sufferers apparently owe their condition to unhealthy lifestyles involving excessive consumption of fat, alcohol and tobacco. Kimbrell does not see transplants as a solution to organ disease but rather better care of the organs whilst they are still healthy. He points out that the 'majority of patients for liver transplants are...suffering from liver disease due to alcohol consumption.' He urges us to 'change our ways of working, living and eating... and find daily routines that better fit our bodies'.⁴ Perhaps it should be added that such routines would follow naturally if people adopted a completely different outlook on life. However, here we are concerned with actual human suffering, albeit sometimes obviously self-inflicted. In any case, failure of the most commonly transplanted vital organ, the kidney, cannot on the whole be simply ascribed to lifestyle.

Live donors

"Greater love hath no man than this, that a man lay down his life for his friends".⁶ Perhaps ethically the least questionable transplants are when living donors volunteer a kidney or part of their liver, lungs or pancreas. This is usually between close relatives, e.g. parent and child. This is partly because the similarity of blood groups and tissue types gives the greater chance of success necessary in such a situation which risks the life of the healthy person whilst undergoing surgery and can compromise their health thereafter. For instance, kidney donors require lifelong dietary control to avoid proteinuria. Paradoxically the transplant can also lead to the breakdown of the relationship between donor and recipient.

Intense motivation is another obvious reason for this form of donation. Recently, a woman who had already given one kidney to save her child, when her second child developed kidney disease, wanted to give her other kidney and go on dialysis. This was refused partly on the grounds that her life would have been at too great a risk in proportion to the likelihood of a successful transplant. Several personal testimonies by living donors can be found on the Internet.⁷

'Dead' donors

Here we approach what is for many people the most problematic aspect of the subject. Most of the very limited supply of organs is from people who have been declared 'brain dead' or more correctly 'brainstem dead' after brain trauma which is usually caused by accidents. Patients diagnosed thus will already be receiving artificial ventilation and other life support measures either as part of their terminal care or in the case of accidents as a matter of routine until the carers are satisfied they have done all they can to help. Breathing and heartbeat continue, but would cease without the mechanical support. I will not dwell on causes for concern arising from the fact that in an American survey 65% of doctors questioned who were making brain death decisions were not clear about the legal and medical criteria of brain death,⁸ nor need we worry unduly about the recent sensational but rare cases in Britain of misdiagnoses involving the 'dead' waking up in the mortuary. Suffice it to say, if properly carried out, this diagnosis of death made by two doctors with no involvement in transplantation should rule out any possibility of the patient's recovery. Reflexes such as pupil response to light, blinking, eye movement when ears are irrigated with ice-cold water, gagging response to throat stimulus and pain must be absent. The ventilator is then stopped to look for efforts at unaided breathing. To certify death, the tests must be repeated at least twice with several hours in between.⁹ An additional requirement in some American states is the absence of signals on the electroencephalogram (EEG) but the usefulness of this is controversial. Indeed, it is argued that protagonists of brain death discourage EEG use because it might sometimes evidence residual life in the brain.⁴⁰ Brain death should certainly not be confused with the persistent vegetative state where only brain cortical function is lost and which can in some cases last for many years. Under present UK law, such patients cannot be used for organ retrieval.

Brain death is now accepted almost worldwide as a definition of death. In Britain it was formalised in 1976 precisely at the time when organ transplantation was becoming increasingly common and there was a growing need for live organs. India did not legalise the definition until 1994,¹⁰ and in Japan, Korea, Poland and Denmark it is still not formally accepted. Most Japanese including politicians still define death in the traditional way, namely irreversible cessation of breathing and heart function. Could the Japanese attitude have a message for us? A bill to revise the definition put before the Diet several years ago has still not been passed. The delay is attributed to the prevailing Shinto, Buddhist and Confucian beliefs^11,12 although according to some it is partly due to paternalism.¹³ People in Japan wanting transplants either die or have them abroad.¹⁴

Brain death tests performed may be fairly good at demonstrating a hopeless prognosis but are very poor at telling us to what extent the patient is still alive. There are several good technical reasons for these assertions. For instance, it has been argued that the respiratory control centre in the brain stem is not always adequately challenged by the UK criteria.⁴⁰

Jonas argues that the slicing of the transplanter's scalpel serves neither therapy nor medical knowledge. It is the final trauma of the diffused sensitivity of the dying person.¹⁶ Before excising an organ such as the heart the donor's blood is replaced with cooling fluids, yet ventilation and circulation are maintained. How do these insults affect the departing soul-spirit?

For an Aristotelian and a Thomist, if the body is alive then the person is alive, regardless of the brain condition. The only convincing evidence for the presence of a dead brain would be a dead body. The signs would be pallor, rigor mortis and decomposition. But instead of forces of dissolution, a whole list of bodily integrative and maintenance processes too extensive to itemise here continue to function at normal or near normal levels in the brain dead. Suffice it to say that the heart, especially when considered in context and not as a pump, could not continue to beat were it not for the rest of the body's remaining support functions. That intensive care works at all and that "organ protective therapy" is at all possible before the organs are removed shows that the donor is still alive.¹⁷ Organ removal therefore entails a killing. However, we cannot go as far as some and call it murder,¹⁶ because no socially sanctioned killing is defined legally as murder.

Even in physical terms, death is a process taking place over a period of time, however short. With organ transplants from 'beating-heart cadavers' (weasel words?) it is only a matter of definition where we place the moment of death, namely at the certification of 'brain death' rather than at the actual death of the patient brought about by 'harvesting' the organs. The certification merely changes the status of someone who is extremely ill to that of a corpse. This act, as with the manipulation of embryo and foetus at the beginning of life, raises deep questions concerning our picture of what a human being is.

Indeed, our world view significantly affects what we do. We create the world in our thinking and thus already have a responsibility for how we think and for clarifying our values. Morality can begin here, long before our thinking is realised in any technology. When we identify human life and death with brain life and death, we ignore the possibility that the whole body is ensouled. The relatively new definition of death is not a scientific but a cultural and ethical matter, if not one of expediency, arising from the materialistic reductionism which prevails in our time. Can we imagine a functional brain out of the context of the rest of the body or must we identify the whole with the function of one of its parts? This could be seen as a relic of Cartesian dualism which splits the human being into a mind for which the body is just a tool. Is the presence of an individuality and their consciousness in the world merely a working brain, as major western religious groups now seem to accept? Or is the brain simply one of the essential conditions for the full manifestation of the individuality in the physical world?

Insights from anthroposophy

The healthy human being can be regarded as comprising three very distinct systems working together in harmony, the nerve-sense system, the rhythmic system and the metabolic-limb system. Although the principle spheres of operation of these systems are in the brain/spinal chord, the heart/lungs and the limbs/abdomen respectively they also work in varying degrees in all parts of the body including the head.¹⁸ The human being considered as a whole must therefore be pictured as diffused over their whole body. Even our memory which science locates in the brain is spread over our whole organism in what Steiner variously calls our life body, our body of formative forces or etheric body.¹⁹

Obviously the kind of pain spoken about here is not the kind which would be elicited when testing reflexes prior to certifying brain death.

Medical manipulation of death

The end of physical life is the beginning of life in spiritland. A Buddhist saying puts this neatly: 'The cause of death is not disease, but birth'. As the ego (spirit, self, I) gradually over a long period is released from the physical, etheric and astral bodies, it is born into a new consciousness which is in a certain sense more intense than before.²⁴ Near death experiences²⁵ and telepathic 'news' of the death of a loved one in battle are often cited as evidence of the continuity of consciousness after death. Brain death could be seen as the beginning of the individuality's new consciousness. Continuing life support while waiting for the organ retrieval team to arrive and do its work is an interference which could be potentially harmful. In response to a question about the influence of post-mortem examination on the destiny of the dead Steiner emphasised that there is no such influence.²⁶ But here we are concerned not with the dead but the dying. Can we be sure that excising organs from one person and keeping them alive in another has no consequences for the karma of those involved?

Pointing to a potential interference with karma is not meant to imply that the time of death is necessarily predestined. On the contrary, in the case of someone drowning, a bystander can in principle freely decide whether or not to risk their life by going to the rescue. Anyway karma is 'interfered' with in so many ways. Is interference during dying of any significance? Amongst doctors who acknowledge the continued existence of the individuality after death there is no universal agreement as to whether continuing intensive care until the heart fails is a help or a hindrance.

Bavastro,²⁷ who prefers the term 'brain failure' to 'brain death', argues that this condition does not mean that the person is not dealing with their situation with quite another kind of consciousness. Although the ego is released from the body, a certain degree of astral activity continues without the ego being involved, for instance twitching and other movements ('Lazarus signs'), 'inexplicable' sweating and other involuntary activities. He feels that human contact is important, including skin contact, massage and other forms of treatment. If this has any longer term effect it can only be for the life after death or a future earthly life. Bavastro does not consider the patient as already dead and therefore would rule out simply switching off the life support system or taking the organs. The person is seen as a whole and receives full ethical medical protection right to the end. Whoever argues that this is a somewhat unusual approach and that Bavastro, a practitioner of anthroposophical medicine, represents a tiny minority, may still wish to consider that doctors in general are by no means in agreement on the brain death definition, not even if it includes a zero line on the EEG. Partial function of the hypothalamo-hypophyseal axis, the temporal lobe, the thalamus and the brainstem can still be present.²⁸

'...[Ahrimanic] beings are able to enter this human body at a definite time before the human being is born, and below the threshold of our consciousness they accompany us. There is only one thing in human life that they absolutely cannot endure: they cannot endure death. Therefore they always leave this human body...before that body succumbs to death. This is a very harsh disappointment again and again, for just what they want to attain - to remain in human bodies beyond death - is thwarted. To do this would be a lofty achievement in the kingdom of these beings. Up until now, they have not attained it.

...had Christ not passed through the Mystery of Golgotha, conditions on earth would have been such that these beings would long ago have attained the possibility of remaining within the human being when he is karmically predestined for death. Then they would have completely triumphed over human evolution on earth...

The existence of contrasting but well-informed views on whether to prolong intensive care after brain death serves to illustrate how greatly the mystery of death challenges our knowledge.

The doctor's dilemma

Faced with the brain dead and the possibility of one or more organ transplants from his 'patient' the doctor can no longer rely on traditional (Hippocratic) medical ethics. At least two patients are now involved. His therapeutic intentions, for instance the intensification of life-support measures, are no longer directed at his dying patient. It should come as no surprise that the decision to apply intensive care can be informed by the organ retrieval potential of the patient. In a sense the patient then becomes a victim. We hear of the 'accident victim' but never the 'organ retrieval victim' not even if the patient never expressed a wish to donate their organs. In the absence of such a wish, at least in this country, the relatives' permission must be sought before the organs are removed. The patient becomes, somewhat euphemistically, a 'brainstem dead organ donor'. By using the term 'victim' instead of 'donor' we would at least acknowledge that what we are doing is not in the patient's interest,³⁰ not even if they had allowed it in a living will (advance directive). Living wills are still an unresolved medico-legal and ethical issue which cannot be discussed here. Suffice it to say that doctors are by no means in agreement as to whether they are ultimately in the patient's interest.³¹

The donor decides

Whilst wanting to encourage a rethink about removing organs from the dying, given the current state of our knowledge I would not want any compromise of a donor's right to donate or a recipient's freedom to opt for transplantation. Such prescriptiveness would not only violate the ethical principle of autonomy³² but would also rule out the possibility of acting on individual moral intuition, the basis of a true ethics.³³ One comes closer to ethical individualism in this matter if one's decision whether or not to allow oneself to become a source of organs in the event of being declared brain dead is made without coercion and with full awareness of all the facts. Full awareness would include understanding the significance of the phrase on the organ donor card 'after my death' and giving at least some consideration to the unknowns, such as the possible soul-spiritual effects of transplants. But where a doctor is faced with a patient who has never reached a decision of this quality, and this would include all children, to allow the relatives to consent on the patient's behalf would violate the patient's autonomy.

Certainly most major religions in the UK support organ donation, including recently the UK Muslim Law (Shariah) Council which accepts brain death as constituting the end of life for the purpose of organ transplant. Becoming a donor is simply a matter of contacting the UK Transplant Support Services Authority¹ stating full name, address, date of birth, sex and which organs you wish to donate. Telling your family and friends will help to ensure that your wishes are carried out. This is necessary because despite having your name on the register and possessing a donor card, in the event of you becoming a potential donor your relatives will still be asked for their permission and may refuse. Indeed in some cases the painfulness of the decision can be greatly intensified if relatives discover only after the death of a loved one that they are a registered donor.

Apart from stepping up the drive to encourage people to carry donor cards several other proposals are being considered for increasing the organ supply. One involves non-therapeutic (elective) ventilation of potential organ donors in cases where the prognosis is known to be hopeless before breathing stops naturally.³⁴ This would clearly not be for the benefit of the patient concerned but for whoever is to receive their organs. It would be one more step down the slippery slope towards killing physically healthy people for their organs as has happened in South America.⁴ Another way to increase the organ supply is to reverse the present situation and presume everyone is a donor unless they register their refusal as is the case in France, Austria and Belgium. This is not favoured in the UK because it is feared that it would produce a public backlash thus reducing the organ supply.

On the other hand if one decides against becoming a donor one remains part of the subversive minority, as too do relatives who refuse. There exists a slight but noticeable tendency to stigmatise this group. It arises partly from the overwhelming cultural acceptance of organ retrieval from the brain dead.

The organ recipient

The recipient, just as much as the donor, should be given all the information they need to make a free informed decision about whether to have a transplant. Many are not aware that the organ they are about to receive has come from a living person,²⁷ that it still bears the stamp of that person and will continue to act as something foreign in their body. For the rest of their lives they must take immunosuppressive drugs to prevent rejection of the replacement organ. Certain organs can even mount an immune attack against the recipient. The immunosuppressives are one of the limitations, sometimes severe, on the quality of life that can be expected after the transplant. It is not surprising that recipients sometimes eventually refuse to comply with immunosuppressive drug therapy. One wonders whether in view of this the deed of organ donation is quite as philanthropic as it is made out to be.

A major breakthrough which made organ transplants possible in the first place was the discovery of drugs such as cyclosporin. These suppress the immune system which is responsible for recognising what is 'non-self' and destroying it. Steroids are also prescribed as immunosuppressants. The facial features which these cause gave rise to the affectionate nickname 'the Harefield hamsters' for the heart-transplant patients at that hospital.³⁷ However, longer term medical advances, such as preparing the recipient's immune system beforehand to receive the organ as if it was one of its own, could eventually replace the reliance on drugs.³⁸

Neve compares organ transplantation with cannibalism, arguing that of the two ways of consuming organs the latter may have less serious karmic consequences.³⁵ Steiner describes how we work on our bodies over many incarnations, freeing them from what is not of our selves. Part of this process involves the metamorphosis of the body into the head of the following incarnation.³⁶ How does the mingling of two bodies, especially involving a vital organ like the heart, affect this process?

Aside from the above concerns, the recipient pondering the way ahead will learn from others who have had the operation, who openly express their joy in numerous books and articles and who campaign to help others like them to receive the gift of life.⁷ As spirit we are already immortal, but we are driven to seeking bodily immortality in purely material ways. I end on a cautionary note from St Paul: 'Know ye not that your body is the temple of the Holy Ghost, which is in you, which ye have of God, and ye are not your own?³⁹

Acknowledgements