The Science and Theology of Death and Organ Donation
Is the determination of death a medical or theological matter? A bioethicist thinks theology has something to offer the conversation on death and organ donation.
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Christians have long debated what happens after we die and the role of death in God’s creation. But, until recently, how we know a person is dead hasn’t received much theological attention. Determination of death is typically understood as a medical rather than a theological question. After all, medical professionals, and not clergy, have the responsibility of “declaring” death.
Yet, skepticism in medicine’s definitions of death abound. In the past, people were worried about declaring someone dead too soon and physicians had rituals to check if a person was really, in fact, dead. Modern technology has allowed us to detect subtle signs of life like a heartbeat and brain activity. While this has certainly expanded our understanding of death, it has also made distinguishing the boundary between life and death more challenging.
It is important, however, for medical professionals to know when a person is dead because dead bodies must be treated differently than living bodies. Vital organs, for example, can only be taken from dead donors. Physicians need to be sure that they are not killing patients when they remove their organs. New techniques in organ donation have caused some clinicians to worry that their patients are not completely dead when their organs are removed. As a Christian bioethicist who works in hospitals, it is important for me to consider whether such fears are warranted. It is also important for me to consider what theology can offer current debates on organ donation.
Modern technology has allowed us to detect subtle signs of life, like a heartbeat and brain activity. While this has certainly expanded our understanding of death, it has also made distinguishing the boundary between life and death more challenging.
A Brief History of Death and Organ Donation
In her book, “Stiff: The Curious Life of Human Cadavers,” Mary Roach describes rituals that were historically often used to confirm death before modern medicine. They often involved physical torture and other inventive measures, like attaching bells to corpses to hear them move. People were understandably afraid of being buried alive. The invention of the stethoscope and other medical instruments eased those fears temporarily because they could detect signs of life that were otherwise imperceptible.
In the mid-twentieth century, however, a new definition of “brain death” reignited old fears. In the late 1960s, the Ad Hoc Committee at Harvard Medical School gathered to talk about patients in irreversible comas. Some patients showed no neurological activity but were still breathing with the help of a ventilator. The Ad Hoc Committee suggested declaring patients without brain function dead. This would create new death criteria. Neurological criteria were eventually included in the Uniform Determination of Death Act (UDDA) in 1981. This act is now the standard for determining death. Today, a person is declared dead either when their heart or brain permanently stops functioning.
The Harvard Ad Hoc Committee believed the new definition of death had two advantages. First, when patients are declared dead based on brain criteria, medical technologies can be removed for use on other patients. Second, “brain dead” patients can be organ donors without breaking the dead donor rule. This rule states that vital organs can only be removed after the patient has died. In other words, organ donation should not cause a patient’s death. Patients who are declared brain dead make ideal organ donors. This is because they can donate their organs before supportive technologies are removed. This helps to keep organs oxygenated and functional.
In my experience as a clinical ethicist, it is difficult for families to accept brain death as death, because their loved one doesn’t look dead. They have a pulse, feel warm to the touch, have normal color, and may even retain some reflexes. Also, medical professionals don’t always treat them as dead. Convincing families to allow their loved one to donate organs, therefore, can be a challenge.
The connection between brain death and organ donation has created some concerns that this new definition of death was primarily meant to increase the supply of organs. In my experience as a clinical ethicist, it is difficult for families to accept brain death as death, because their loved one doesn’t look dead. They have a pulse, feel warm to the touch, have normal color, and may even retain some reflexes. Also, medical professionals don’t always treat them as dead. Convincing families to allow their loved one to donate organs, therefore, can be a challenge.
New ways to manage cardiac death have also led to concerns about organ donation and procurement. When a family decides to take a patient off life support, transplant surgeons must wait at least five minutes before declaring death. This ensures that there is no sudden return of heart or lung function. Transplant surgeons can then retrieve organs for donation. This process is known as “donation after circulatory death (DCD).” This waiting period can damage organs, however, making them unfit for transplant. A new technique called normothermic regional perfusion with controlled donation after circulatory determination of death, or NRP-cDCD, solves this issue. It uses a machine to send oxygenated blood to the organs meant for transplant. At the same time, it stops blood flow to the donor’s brain. In practice, when blood flow resumes to the heart during NRP-cDCD, the donor’s heart starts beating again while still in the individual’s chest.
The U.K. started NRP-cDCD donations in 2015 but has since paused them. Restarting hearts in patients declared dead made some doctors uneasy. Moreover, early studies showed blood still reached the brain of the dead person, even after surgeons clamped off those vessels. Since DCD donation often requires permanent cessation of brain circulation, some surgeons felt they were potentially violating the dead donor rule. In simpler terms, organ donors with brain flow and a beating heart do not appear dead to all surgeons. Despite differing opinions among experts, countries like the United States still employ NRP-cDCD.
A Christian Response
As a theological bioethicist, I sometimes struggle with how to craft a Christian response to certain medical debates. Do Christians have something unique to say about when or how a person should be considered dead? Certainly, we cannot do so without substantial help from the medical sciences. There isn’t a unique Christian definition of death. Medical science and clinical practice must inform how we understand biological death. Theological principles, however, can guide debates on organ transplantation.
Christian theologians believe that there is a meaningful distinction between the living and the dead. Death is significant, because resurrection (our own and Christ’s) comes through death. Yet, debates over NRP-cDCD reveal what many scientists have long understood—biological death is more of a process than an exact moment. Hearts, brains, cells, and other biological processes in the human body do not always permanently cease to function at the same time. This reality makes it difficult to define the moment of death.
Although the exact moment of death may not be clear, it is still crucial to distinguish between life and death. This distinction is important because we have different obligations to the living and the deceased. As Christians, we should care for and prepare the bodies of the deceased, give them a proper burial, and mourn for them. However, we are not obligated to provide life-prolonging technologies. For this reason, we need to agree on when death occurs and avoid ending others’ lives prematurely.
Do Christians have something unique to say about when or how a person should be considered dead? Certainly, we cannot do so without substantial help from the medical sciences…Medical science and clinical practice must inform how we understand biological death. Theological principles, however, can guide debates on organ transplantation.
It is also important for Christians to affirm the dead donor rule against those who seek to abandon it. The fifth commandment (Exodus 23: 13) clearly condemns killing. The Christian tradition has also emphasized the duty to preserve our own lives as well as the lives of others. Our lives are a divine loan that we must respect. We ought not to kill patients to recover their organs, even if the donor consents to it, and even if doing so would save the lives of other individuals. Christian bioethics must encompass more than respect for individual autonomy and counting lives saved. We are unique and beloved creations of God, even when we are old, sick, injured, or near death. Any declaration that a patient is “dead enough” to donate organs, therefore, should give us pause.
At the same time, Christians ought not to cling so desperately to life that we become vitalists—or people who believe that life is worth preserving at any cost. Our duty to preserve human life is not unlimited. Humans are finite creatures whose lives will come to an end, and Christians can take heart that death is not the end of the story. Organ donation is an earthly practice that helps to remind us that death can bring new life. More Christians should become organ donors to help meet the growing need for organs in our communities.
Likewise, our fear of death should not prevent us from setting necessary limits on the medical care we seek at the end of life. Accepting the inevitability of death frees us from making unreasonable demands on others as well as our medical system. Accepting our mortality may also help ensure that our organs have a chance of being useful to another person.
I have yet to meet a physician or bioethicist who is not deeply concerned about the shortage of transplantable organs. Yet many of these same experts are worried that NRP-cDCD involves potential acts of killing. The worry is not merely one of public perception or that fewer people will be willing to donate organs if they believe organ donation causes death. Experts have principled concerns that surgeons are retrieving vital organs from living people. There are empirical, ethical, and legal questions that have yet to be resolved in NRP-cDCD. For this reason, prudence may dictate a pause on the practice for the sake of meaningful investigation and dialogue.
…Christians can take heart that death is not the end of the story. Organ donation is an earthly practice that helps to remind us that death can bring new life. More Christians should become organ donors to help meet the growing need for organs in our communities.
Techniques of organ donation, like many medical practices, are always evolving and require ethical evaluation. It is important for Christians to continue to discuss the ethical issues surrounding these practices to help ensure that important theological values are not abandoned as we face difficult decisions in medicine.
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