Be clear on 'life' and 'death'.

Thank you for publishing the interesting exchange between Dr. Robert Sade and Dr. Michael A. Grodin on organ donation after cardiac arrest--misnamed "cardiac death" in the article ("Should organ donation after cardiac death be promoted and adopted more widely?" Point/Counterpoint, Oct. 15, 2007, p. 9).

I agree with Dr. Grodin that more truth and less obfuscation are called for, but I believe that organ donation after cardiac arrest may be justifiable in some circumstances.

There is only one kind of death of a human person: the cessation of all the functions of the body as an integrated whole. A person is either living or dead. There is no intermediate state. A living person is "present," even if in a gravely compromised state. A dead person has "departed." A "dying" person is a living person.

But, although we must be clear on the concepts of life and death, we do not have the ability to observe the exact moment of death. There is a period of uncertainty between the cessation of vital signs and the onset of decay. The only certainty that death has occurred is in signs of decay, e.g. rigor mortis, and by then viable organ donation is impossible. Nevertheless, during that time, one must ethically respect the person as a possibly living human being.

Death was once thought equivalent to cardiac arrest. Clearly, the ability to resuscitate should have put to rest that misunderstanding. The other prevalent false concept is that a person who has suffered grave brain injury, even persistent total loss of brain function, is dead. I once heard a physician say, "The neurologist declared the patient brain-dead, so we turned off the ventilator and let him die." Such apparent confusion may evince an intuitive understanding that we disregard at our peril.

The current confusion arose with the tainted concept of "brain death," devised to justify organ donation. The cessation of function of a single organ, even as one as essential as the heart or the brain, does not constitute the death of the person. Are we expected to believe that there are two classes of dead people, one with functioning brains and nonfunctioning hearts, and the other with functioning hearts and nonfunctioning brains?

It is unethical (and immoral) to remove a vital organ from a living person, because doing so kills the person. How then do I believe that donation after cardiac arrest could ever be ethical?

The problem is not organ donation, but the pretense that certain gravely ill, injured, or even "dying" people are already dead. Is organ donation by a living person ever ethical? Clearly yes. Unilateral kidney donation, for example, is widely understood to be a laudable act. Can a heart ever be removed ethically from a living person? Yes, but only after it has ceased to be a vital organ. If the decision has been appropriately made, with the patient's prior or proxy consent, it is permissible to discontinue extraordinary measures of life support. Then, once cardiac arrest has occurred, there being no reasonable cause for resuscitation, the nonbeating heart is, for the few remaining minutes of the patient's life, no longer a vital organ.

Subject to all the usual conditions (separate donor caregivers and transplant team, appropriate consent, careful education of the family, etc.), there seems to be no moral barrier to the removal of organs in these cases. Such an act does not cause the patient's death, which in these circumstances is inevitable, anticipated, and accepted. If it is clearly understood, such a selfless act by the patient in his last moments may provide much comfort to the grieving family.

What I find repugnant is not the donation of organs in these circumstances, but the manufacture of false concepts such as "brain death" and "cardiac death" to justify a utilitarian end. Only scrupulous regard for the truth will let us make moral and ethical decisions in these difficult cases.

William G. White, M.D.

Franklin Park, Ill.