Respect for persons: beyond the mortal world.

Although death is an inevitable and quintessentially final state of living beings, the moment at which one becomes dead remains an elusive and controversial occurrence. Mechanical ventilation underscores this complexity, and the ability to transplant human organs amplifies and intensifies the debate. Transplantation has always been subject to the dead donor rule, a requirement that the patient must be declared dead prior to the removal of any vital organ. The traditional concept of death included cessation of the cardiorespiratory system, and in many parts of the world a period of time for observation of clinical findings of death, primarily loss of the ability to maintain body temperature. There was an appreciation of the fact that different organs ‘‘died’’ at different times, but the death of a person was thought to occur after all of the organs ceased function. Mechanical ventilation allowed for patients with no neurologic function to be maintained on life support, and clinicians were confronted with a body devoid of a functional central nervous system. The classification of such a state remains unsettled. In 1959, Wertheimer wrote of the ‘‘death of the nervous system,’’ and Mollaret and Goulon’s ‘‘coma depasse,’’ a state beyond coma, added a linguistic flare to the condition. The first codified criteria for brain death emerged from a European CIBA symposium in 1965 and from Harvard in 1968; however, the first brain-dead donor transplant occurred in 1963 in Belgium by Dr Guy Alexandre. The US government passed the Uniform Determination of Death Act in 1981, which defines death as irreversible cessation of function in either the cardiorespiratory system or the entire brain. A recent President’s Council on Bioethics report endorses this definition of brain death, but equivocates by citing that some members expressed ‘‘significant uncertainty about the neurologic standard.’’ Uncertainty arises from both religious/cultural and scientific sources. In Jewish Halacha law, a beating heart signifies life; the concept of brain death is patently rejected. In many Asian cultures, the concept of brain death is not accepted as legitimate death. Similarly, scientific observation and inquiry have documented phenomena that rattle the foundation of the brain death definition. Some ‘‘brain-dead’’ patients maintain thermoregulatory ability and other posterior pituitary function, such as salt homeostasis. Technically, they have not demonstrated irreversible cessation of function. In many cases, these neurologic functions are not deemed ‘‘significant,’’ and organ procurement proceeds. There are some who contend that these patients are not in fact dead, but have no chance of recovery of consciousness or the ability to interact, and may still be used as donors as long as appropriate consent is obtained. Although one may find this description more scientifically accurate, the dead donor rule explicitly forbids this practice if the patient is not pronounced dead by the clinician. In the article by Cummings et al, a case is presented in which brain death is established, the family is in accord with organ procurement, and subsequently the patient undergoes cardiac arrest. The authors contend that it is permissible based on medical expediency to perform cardiac resuscitation as this serves the ultimate goal of attempting to provide organs with minimal ischemic damage. Consent for cardiac resuscitation is not necessary, as the patient is now in the preoperative phase of organ procurement. The authors are, in fact, proposing that the physician acts as if the patient is dead; the family no longer holds decision-making capability. That being said, the authors also state that the issue of potential cardiopulmonary resuscitation (CPR) could be addressed with the family during the discussion of organ donation. They suggest that consent for organ procurement could include an explicit acceptance of CPR. The authors believe that this will be more inclusive for the family and potentially respectful to beliefs or values of the family. However, what if a family member agrees that organ donation of their brain-dead loved one is acceptable, but feels that CPR is not in keeping with the patients’ wishes? Should the family member exclude CPR from being performed? The tension described in the case report brings to light the clinician’s sense that, although the person undergoing CPR is dead (by brain death criteria), respect for persons still applies, even in death. If the potential organ donor is truly dead, then the goal of medical care is to avoid ischemia and preserve organ integrity for the recipient’s benefit. The notion of obtaining a traditional consent for treatments or procedures becomes obsolete. The key concern is to maintain organ perfusion and avoid