May 19 VIII/S
ANENCEPHALIC INFANTS: ALIVE OR DEAD?
In response to a shortage of kidneys for transplant into children, a medical team in West Germany has initiated the practice of removing kidneys from anencephalic infants. (l) The medical team announces that the transplants are successful. But, of course, the donor dies because vital organs have been removed. The medical team defends their action by maintaining that anencephalic infants should "be considered brain dead." Moreover, they state that "the anencephalic fetus, because of the absence of brain development, has never been alive despite the presence of heartbeat." Is there any scientific justification for maintaining that an anencephalic infant is brain dead, or that it may be treated as though it were already dead though its heart beats spontaneously?
Principles
Anencephaly is the congenital absence of the cranial vault with the cerebral hemispheres completely missing or reduced to small masses. The malformation results in a severely underdeveloped, or undeveloped, cerebral cortex. However, the brain stem, or lower brain, does develop and integrates digestion, respiration, and other human functions at least for a short time if the infant is born alive.
Would it be reasonable to consider a an anencephalic infant dead simply because the cerebral cortex does not develop? One characteristic of living things which is absent in the dead is the body's capacity to organize and regulate itself. Death is that moment when the body's physiological system ceases to constitute a unified homeostatic system and becomes disorganized into a mere collection of heterogeneous chemical substances. If time is not a factor, even the lay person can judge that another person is dead because after a time the dead body will lose all signs of life and begin to decay. But for legal and medical reasons, a decision that death has occurred is usually required shortly after the event. Thus medical science seeks clinical criteria to define and diagnose the death of an individual with greater celerity.
An extensive summary in regard to the clinical criteria for determining human death is found in Defining Death, the report of the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. (2) In accord with traditional practice the Commission accepts irreversible cessation of spontaneous cardio-pulmonary function as one clinical criterion for death. But the Commission also maintains that death may be determined if brain function is lacking because the brain integrates the activity of the body. However, in order using brain function as the criterion, the Commission requires cessation "of all functions of the entire brain including the brain stem."
That "brain death" involves more than the higher brain function also was made clear in one of the first scientific seminars to investigate this topic. (3) The seminar participants agreed that "brain death is defined as irreversible destruction of the neuronal contents of the intracranial cavity. This includes both cerebral hemispheres, including cortex and deep structures, as well as the brain stem and the cerebellum. An equivalent term is total brain infarction to the first cervical level of the spinal cord" (p.7).
The President's Commission rejects explicitly the theory that higher brain death alone, that is, absence of function in the cortex with the brain stem retaining its function, would constitute a criterion for human death because:
"First...it is not known which portions of the brain are responsible for cognition and consciousness; what little is known points to substantial interconnections among brainstem, subcortical structures and the neocortex. Thus, the "higher brain" may well exist only as a metaphorical concept, not in reality. Second, even when the sites of certain aspects of consciousness can be found, their cessation often cannot be assessed with the certainty that would be required in applying a statutory definition" (p.40).If only higher brain function were assessed in determining death it would violate our social values as well because it would allow the burial of people while they are still breathing and pulsating spontaneously.
Could development of the cerebral cortex be considered a "marker event" separating prehuman and human development? Is there any scientific evidence which indicates that because an anencephalic infant does not develop a cerebral cortex that it is not a human being? In 1985, when studying the matter of experimentation on human embryos, a Select Committee of the Parliament of the Commonwealth of Australia stated: "No marker event advanced carried such weight that different principles should apply to distinguish the fertilized ovum from that which all would agree is a human subject." (4) Thus, the Select Committee rejects as unscientific the notion that there are markers in the progressive development of an embryo, such as development of the primitive streak or the cerebral cortex, which justify maintaining that human life begins after fertilization.
Discussion
Though the anencephalic infant may not develop in a manner that fulfills the full potential usually associated with "person," there is no scientific justification to consider anencephalic infants as dead. Rather, they should be considered living human beings until total brain death occurs. True, an anencephalic infant is a severely debilitated human being and a human being that will not live for long. Because there is no effective means of overcoming the pathology from which the anencephalic infant suffers, therapeutic care may be withheld. But there is a real and dramatic difference between allowing a person to die because a serious pathology cannot be overcome and directly killing an innocent human being. This difference mandates that the anencephalic infant not be the donor of human organs until after it is totally brain dead. Anticipating the death of the infant and keeping its body fluids flowing after death through use of a respirator would not be unethical. But no organs should be removed until death has been certified from clinical signs.
Conclusion
Our era has a strong inclination to allow actions which are harmful to the weak if a "greater good" is promised. But experience and history indicate vividly that we ultimately regret such actions.
Kevin O'Rourke, OP
Footnotes 1. Holzgreve et al, "Kidney Transplantation from Anencephalic Donors." New England Journal of Medicine, v.316, n.17 (Apr.23, 1987).
2. President's Commission, Defining Death (1981).
3. NY Academy of Science, Brain Death. ANYAA 9 315 1-545 (1978).
4. Senate Select Committee, Human Embryo Experimentation in Australia (1985).
| INDEX | © Kevin O'Rourke, O.P.