The Unknown Harvest: Organ Donation and the Definition of Death

High Stakes, Vital Boundaries

Since the first successful kidney transplant in 1954, organ donation has become a means of yearly saving thousands of lives.1 In the USA alone, where the wait list for organs has over 100,000 names, 17 people per day die awaiting a transplant.2 While many organs including kidneys, liver segments, lung lobes, and portions of pancreases and intestines may come from living donors,3 hearts can (understandably) come only from deceased donors. This point highlights a vital concept: the dead donor rule.

Although not a law, the dead donor rule is an ethical standard mandating that a person cannot be killed for or through organ donation.4 As John Robertson observed, “The dead donor rule is a centerpiece of the social order’s commitment to respect for persons and human life. It is also the ethical linchpin of a voluntary system of organ donation, and helps maintain public trust in the organ procurement system.”5 Even so, the need for lifesaving organs inspires multiple work-arounds.

One work-around is simply to redefine death, so that even people with heartbeats or certain types of brain activity can be deemed “dead.” Another way to increase organ availability without ditching the dead donor rule is by allowing euthanasia or assisted suicide. In Canada, for instance, where over 31,000 people were killed by physicians from 2016 to 2021,6 rates of post-euthanasia organ donation surpass those of all other countries.7 A third work-around is “organ conscription,” where organs become government property upon a person’s demise. According to Oxford bioethicists Dominic Wilkinson and Julian Savulescu, “Organ Conscription would have the greatest potential to increase the numbers of organs available for transplantation, though it would come at the cost of patient and family autonomy.”8 These ethicists added that the next best way to increase organ availability “would be Organ Donation Euthanasia (ODE),”9 in which an anesthetized person is killed by organ removal—an open rejection of the dead donor rule.10

While Wilkinson and Savulescu champion voluntary ODE, the reality is that even in countries with “safeguards” for legal euthanasia, not all euthanasia is voluntary. In the Netherlands, for instance, data as of 2021 reveals 517 cases of “terminating life without the express request of the patient.”11 Meanwhile in China, where euthanasia remains illegal,12 a “transplantation tourism” market is evidently fueled by involuntary harvest from prisoners.13

All these means to “extend” the dead donor rule underscore why Christians need to be involved in thinking about organ donation ethics and highlight how even lifesaving actions must take place within ethical boundaries. How can a biblical worldview help with drawing those boundaries? The answer requires first contrasting biblical and secular thinking about life and death.

Life, Death, and Worldviews

A biblical worldview recognizes humans as embodied, relational, created beings made in God’s image. As finite image bearers, humans have inherent dignity, contingency, and accountability to their Creator. Human rebellion resulted in a fallen world, where death and suffering are unnatural but inevitable. Yet Jesus’ victory over death offers ultimate hope, enabling us to view death as a “conquered enemy,” to be neither sought through suicide nor futilely resisted at any expense (vitalism).14 Importantly, a biblical view of death also allows for delineating a valid distinction between withdrawing futile treatment and actively killing someone.15

While we await death’s final abolishment (1 Corinthians 15:26), we are responsible to love others, including by mitigating the fall’s effects and by protecting vulnerable humans from exploitation.

While we await death’s final abolishment (1 Corinthians 15:26), we are responsible to love others, including by mitigating the fall’s effects and by protecting vulnerable humans from exploitation. We must exercise these responsibilities within moral boundaries established by God’s nature.16 Actions, intentions, character, and attitudes all matter biblically for moral decision-making, and noble ends do not justify any means.17

In contrast, secularism assumes humans evolved without a Creator. Morals are socio-evolutionary constructs,18 allowing for a utilitarian ethic by which ends can justify any means.19 This worldview aligns with expressive individualism, which deifies rational individuals as their own truth authorities. This idea lets people with the most capacity to assert their autonomy make decisions at the expense of others who lack this capacity, including the preborn, severely disabled, and comatose.20 In secular societies, such humans may be considered “less worthy” of life, implying that their organs may be justifiably taken for those deemed “more worthy.”

Defining Death

These two worldviews offer vastly different foundations for understanding death. Scripture speaks of death as breathing one’s last, giving up one’s spirit, and (for Christians) being present with the Lord.21 Death is a separation of soul from body, marked by the absence of “the breath of life.”22 We cannot watch the soul depart; we can only observe stages of bodily decline.

Historically, death has been understood as a biological event marked by the permanent loss of breathing and pulse, representing the “failure of the entire organism.”23 But the lines between life and death seemed to blur in the early ‘50s, with the invention of life support technologies.24 Then, the stakes surrounding questions of death’s definition heightened with the first successful heart transplant in 1967.25

Mere months later, the Harvard Medical School redefined death as “irreversible coma.”26 Among the motives listed for this redefinition were “the need of hospital beds” and “controversy in obtaining organs for transplantation.”27 Then in 1971, another important conceptual shift occurred when ethical discourse switched from emphasizing respect for persons to respect for autonomous decisions.28

Two years later, the President’s Commission for Medical Ethics decided that death can be defined by either (1) the irreversible loss of breathing and a heartbeat or (2) “whole brain death,” understood as “irreversible cessation of all functions of the entire brain, including the brainstem.”29 (Notably, people considered brain-dead need ventilators to keep breathing, but their hearts continue beating on their own.30)

These definitions became American law with the Uniform Determination of Death Act (UDDA), established in 198031 and currently being revised in 2023.32 Correspondingly, the American Academy of Neurology (AAN) developed guidelines for diagnosing brain death as the “irreversible loss of function of the brain, including the brainstem.”33

Is Brain Death Valid?

These definitions and guidelines relied on a biological concept of death as the loss of “the integrated functioning of the organism as a whole.”34 The idea was that, without the brain overseeing all the processes that let the body work together to maintain homeostasis, the body would disintegrate in death.35 But later research showed this idea false. People sustained on ventilators after being thoroughly diagnosed as “brain-dead” continue to maintain homeostasis, fight infections, digest nutrients, eliminate waste, heal wounds, and can undergo growth, puberty, and childbearing.36 As traditionally understood, corpses do none of these activities.

But there is more. Patients deemed brain-dead may also exhibit motions many physicians interpret as spinal reflexes, but which others argue “are of the brainstem and not of spinal origin.”37 And in an estimated 50% of brain-death diagnoses, the hypothalamus—part of the brain responsible for performing homeostatic functions—is still working.38 Other research revealed ongoing EEG activity in 20% of 56 patients who had been declared brain-dead.39

Perhaps most unsettling, people declared dead either by brain criteria or by a short absence of pulse are well-known to exhibit stress responses—including increased heart rate, elevated blood pressure, sweating, lacrimation (crying), and surges of stress-related hormones—when cut open for unanesthetized organ retrieval.40 Many physicians attribute these responses to spinal reflexes;41 others point out that similar responses to surgery occur even in people who, due to spinal injuries, cannot feel pain;42 however, others still caution that patient awareness is both unknown and possible and advocate for organ donors to receive anesthesia.43

Even while acknowledging what “brain-dead” people can still do, the President’s Council for Bioethics in 2008 maintained the definitions of death as (1) irreversible loss of heartbeat and breathing or (2) brain death, understood as “total brain failure.”44 But oddly, this version of “total” nonetheless allows for some ongoing brain function (e.g., of the hypothalamus). How can that be? In response, some reply that brain death simply entails no critical brain function or that the hypothalamus performs activity rather than function.45 But others say these arguments are merely motivated wordplay, for the hypothalamus does perform physiological functions which can be rightly described as critical.46 For such reasons, the claim that “no brain function” can coincide with “some brain function” has been critiqued as “an impressive feat of bold unconcern for logical contradiction.”47 Yet this claim has persisted in the updated AAN guidelines, the 2020 definition of brain death by the World Brain Death Project, and proposals for revisions of the UDDA.48

Tellingly, the President’s Council for Bioethics defended its stance by arguing that even though brain-dead patients may not have total loss of brain function, they can no longer “carry out the fundamental work of a living organism.”49 This fundamental work, said the Council, includes the ability to sense and respond to the environment, along with “the capacity and drive to act on this environment on his or her own behalf.”50 But others respond that (1) biologically, brain-dead patients do engage in forms of these activities, albeit presumably unconsciously and (2) the Council’s stance represents a concerning shift from a biological to a philosophical concept of human life and death.51 This new philosophical understanding, consistent with expressive individualism, views only certain kinds of human lives (namely, the autonomous kind that allows for acting on one’s own behalf) as “worth living.”

But not everyone on the Council agreed. Two personal statements by Council members—including the Chairman, Edmund Pellegrino—cautioned that the biological observations clinicians currently use for declaring people dead52 do not necessarily lead to valid philosophical declarations of death.53 For instance, we cannot say that a person without a certain type of brain function is dead without making a prior philosophical assumption that personhood depends on this function. Pellegrino surmised, “In my view, the reasons that favor the neurological standard are not compelling. The clinical tests and signs that support it are as subject to doubt as those of the cardiopulmonary standard.”54

Problems with Testing for Brain Death

What doubt was Pellegrino indicating? Answering this requires outlining the current AAN suggested guidelines for declaring brain death.55 First, the physicians must ensure the coma has a known cause established by careful documentation. Then, confounding conditions that mimic brain death must be ruled out.56 Next, the physicians test for responses to stimuli, including sound, light, cold, pressure, or pain. Then, the patient typically undergoes an apnea test, which involves receiving oxygen while disconnected from a ventilator. This allows for checking if the patient tries to breathe spontaneously. If no breathing efforts happen before the patient’s blood CO₂ builds up to a certain level, the patient can be declared brain-dead.57

Unfortunately, these guidelines are not always rigorously followed.58 And even when they are, concerns remain about the guidelines’ adequacy. A recent statement composed by neurology professor Alan Shewmon and signed by over 120 medical, legal, or bioethical experts expressed such concerns on at least four levels:59

1. Detecting awareness:

   Doctors can use tests to observe whether a patient responds to stimuli, but these observations cannot necessarily confirm if the patient is aware of the stimuli despite being unable to respond. Assuming that patients are unconscious simply because there is no evidence they are conscious is an appeal to ignorance fallacy.

2. Confirming total loss of function:

   Physicians do not (and in some respects, cannot) directly test all brain function, such as hypothalamic activity.60 Therefore, decades’ worth of brain death declarations have not conformed to the UDDA definition of “irreversible cessation of all functions of the entire brain.”61

3. Confirming irreversibility:

   Brain death tests do not necessarily confirm irreversible loss of brain functions. Not only do they fail to provide a “direct window into the structural integrity of the parts of the brain responsible for those functions,”62 but they also usually require observing the patient for only a matter of hours. However, as cases of people who have recovered various levels of functionality after a diagnosis of brain death reveal, mere hours may not always let an injured brain show what it can really do.63

4. Eliminating confounders:

   Current testing procedures do not (and perhaps cannot) rule out all potentially reversible conditions that mimic brain death, leading to false diagnoses of brain death. An example is global ischemic penumbra (GIP), where blood flow to the brain is low enough that patients cannot respond to testing but high enough that many of the brain’s cells stay alive. During the process leading to brain death, decreasing blood flow rates necessarily pass through a range that is consistent with GIP without necessarily indicating brain death—though patients tested during this stage would be declared brain-dead.64 Such factors highlight the significance of Joffe et al.’s comment that “[in] properly diagnosed cases of BD [brain death], the following findings occur if tested for: ongoing cerebral blood flow by radionuclide angiography in ~20%, and lack of extensive brain pathological destruction in over 20% of cases.”65

Several common responses to these concerns maintain that (1) brain death has been widely accepted as valid for decades and (2) no one properly declared brain-dead has recovered. Furthermore, (3) brain death declarations unlock an important source of lifesaving organs from patients with exceedingly poor prognoses, and (4) questioning brain death or administering anesthetic during organ donation will diminish public trust in the organ procural system.66

But in response to (1), a concept is not necessarily valid simply because its use is widespread or long running. In response to (2), Shewmon, Joffe, and others argue that some patients have recovered brain function despite a brain death declaration in line with the AAN guidelines; furthermore, most patients deemed brain-dead are not given the chance to recover, so the claim that none recover is a self-fulfilling prophecy.67 And in response to (3) and (4), noble ends cannot justify an affront to human life, regardless of whether that life is considered “worth living.”

Concerns with Organ Donation Procedures

Highlighting the significance of this debate, the Global Observatory on Donation and Transplantation reported that 78% of organs from nonliving donors in 2021 came from patients considered brain-dead (i.e., from “heart-beating donors”).68 The rest would presumably have come from patients declared dead by cardiopulmonary criteria (i.e., from “non-heart-beating donors”). Both donation procedures raise concerns surrounding (1) the irreversibility of the death diagnosis and (2) unknowns about patient awareness.

Regarding the first concern, the UDDA (at least until its 2023 revision) requires that brain death and cardiac death be understood as irreversible conditions.69 But as discussed above, current brain death diagnostic practices do not rule out all potentially reversible conditions. And while organs are commonly harvested after two to five minutes of cardiac arrest, researchers have documented multiple cases of hearts automatically restarting after this timeframe.70 In one tragic case, a women declared brain-dead after two minutes without a heartbeat began gasping during organ removal.71 She then received a lethal dose of fentanyl, and her death was declared a homicide.72 Even if patients’ hearts do not spontaneously restart, resuscitation can restore a person’s heartbeat well after cardiac arrest. A heartbeat’s cessation after two minutes is therefore not necessarily irreversible, even though patients may ask in advance not to be resuscitated. So, proposals to update the UDDA have called for viewing death-related criteria as permanent rather than irreversible.73 However, Joffe et al., point out this is like calling a drowning man “dead” simply because no one is going to save him.74

The second concern is the possibility of patient awareness, given that donors declared “dead” often still exhibit certain forms of brain activity and stress responses to surgery. While stating that these responses are “probably of spinal origin” and not necessarily a reaction to pain, neurosurgeons P. J. Young and B. F. Matta nevertheless concluded that for the donor’s benefit, “sedation and analgesia should be given with muscle relaxation for organ donation.”75 More recently, other authors representing Harvard Medical School and the University of Toronto reaffirmed, “Though there is a very minute chance that patients declared dead by neurologic criteria can experience pain, a cautionary approach is the most ethically sound.”76

NRP: Even More Concerning

Both these concerns of irreversibility and patient awareness heighten regarding an emerging organ procural technique known as normothermic regional perfusion (NRP). In NRP, surgeons wait two to five minutes after cardiac arrest, then open the patient’s chest, clamp the arteries leading to the head to stop blood flow to the brain, and restart circulation until the heart beats on its own again.77 This allows warm blood to continue circulating the organs, preventing them from deteriorating. As the American College of Physicians stated in 2021, NRP “is more accurately described as organ retrieval after cardiopulmonary arrest and the induction of brain death.”78 Despite ongoing controversy, NRP not only happens in the US, UK, and Europe but is gaining popularity.79

NRP apparently violates the criterion of irreversibility for both cardiac death and brain death. Clearly, the cardiac death declaration involved is not irreversible (or even “permanent”), because the heart is restarted.80 And if irreversible brain death had already occurred due to the two to five-minute lack of pulse, why would the surgeons need to clamp the artery?81 Advocates for NRP respond that this technique “does not cause brain death”82 but simply “ensures natural progression to cessation of brain function,”83 adding that the same result happens in standard non-heart-beating organ donations when surgeons flush the heart with cold liquid.84 But other physicians counter that a clamped artery is hardly natural; standard techniques do not deliberately stop brain circulation and do not restart the heart.85

Underscoring these concerns is data from a 2022 study of NPR in 16 pigs.86 The authors opened by stating, “The cerebral effect of clamping following normothermic regional perfusion (NRP) in donation after circulatory death (DCD) remains unknown.” In other words, although surgeons have performed NPR on humans for years, no one had tested whether clamping brain-related arteries works. So, the researchers allowed the pigs’ hearts to stop beating for eight (not just five) minutes and performed NPR, clamping only some pigs’ aortas. Results revealed that while clamps “ensured permanent cessation of brain function” in the pigs that had them, the pigs whose hearts were restarted without clamps not only exhibited brain activity but also started gasping. Clearly, the pigs without clamps could not be considered dead by any standard. The loss of brain function in the clamped pigs, meanwhile, affirms that the clamps do cause brain death. So, using either definition of death, this study’s findings discredit claims that NRP does not violate the dead donor rule.87

How Should Christians Respond?

But even noble efforts must occur within biblical moral boundaries entailing high respect for all human lives—not just those which meet expressive individualism’s ideals.

Faced with these realities concerning organ donation and the definition of death, how can Christians respond? Biblically, we want to mitigate the effects of the fall, and organ donation offers an effective way to do so. But even noble efforts must occur within biblical moral boundaries entailing high respect for all human lives—not just those which meet expressive individualism’s ideals. And a key biblical boundary is that innocent human life must not be taken.88 So, there must be zero doubt as to whether a person is dead before organ donation.

Notably, disagreement remains even among Christians about whether brain death is valid, and whether some brain functions (e.g., the hypothalamus) can persist after “brain death.” But for the same reason that demolishing a building would be wrong if a person could still be inside, we should not destroy a human body if their soul (much less, any conscious awareness) may be present.89 Given that not even noble goals can justify violating an image bearer, a strong case can be made to err on the side of caution by rejecting the ethical validity of many current organ donation procedures and brain death declaration practices.

Importantly, this rejection does not require embracing vitalism. Futile treatment can legitimately be withdrawn from genuinely near-death patients. But those patients must be given compassionate palliative care and be allowed to die truly, irreversibly, and indisputably before organ procurement. Neither does biblically grounded caution require rejecting organ transplantation performed within clear ethical boundaries that align with God’s Word. Such practices may include donation from living donors and donors deemed truly irreversibly dead by cardiopulmonary criteria.90 These boundaries will limit the availability of organs, but so does any boundary that prevents killing humans for their organs.

Meanwhile, Christian researchers can look for other ways to widen organ availability—for instance, via frozen organs or lab-grown organs—to mitigate the effects of the fall without violating ethical boundaries.91 Christian doctors can draw biblical conclusions based on their best knowledge regarding the definition of death and can refuse to violate their consciousness by affronting a patient who may still be alive. Christian citizens and patients can check their local governments’ organ transplantation policies and opt out of donating or receiving organs in ways that violate biblically based personal convictions. And Christian families can advocate for hospitalized loved ones to ensure their organs are not removed before they are irreversibly dead.

Summing Up

In summary, the ethically treacherous terrain surrounding death definitions and organ donation requires that Christians be prepared with biblical understanding, scientific knowledge, and practical wisdom in response. A biblical understanding supports efforts to mitigate the fall’s effects, but only within clear boundaries that respect image bearers and shun the taking of innocent human life. Current scientific knowledge leaves many unknowns regarding whether today’s organ procurement practices violate those boundaries. But what is known (including the reality that many “deceased” organ donors have not, in fact, irreversibly lost their circulation or total brain function) demands practical responses from Christian researchers, doctors, citizens, patients, and family members. Biblical wisdom suggests this response should err on the side of caution by refusing to harvest organs when there is any controversy regarding whether a patient is dead. By maintaining biblical boundaries and seeking ways to help others within these boundaries, Christians can hold the line on respect for human life on issues where the stakes could hardly be higher.

Acknowledgements: I am deeply grateful to the physicians and bioethicists whose presentations on brain death and organ donation were instrumental in helping me to identify key issues and references to highlight in this article, including the three speakers who presented on these topics at the Center for Bioethics and Human Dignity’s 2023 Annual Conference, The Christian Stake in Bioethics Revisited, and Dr. Heidi Klessig, whose webinar “Organ Donation: The Good, The Bad, The Ugly” supplied further helpful information. More information on this important issue will be available in Dr. Kessing’s new book, The Brain Death Fallacy, coming in October 2023.