Neurological Criteria of Ascertaining of Death and the Moral Dilemma in Catholic Hospitals in India

Medical technology, competencies of doctors, social awareness on the possibilities of medicine have formed a powerful drive to the transplants of vital organs from the deceased. Many individuals who were at the edge of the death were brought back to life as a result of this changed scenario in Kerala. Some of the Catholic hospitals have been in the forefront of this movement and they are widely appreciated by the society for their social commitment and commitment to the life. The time between the death and removal of the organ is critical for the success of transplant. If a preoccupation for the success of surgery overtakes the respect for the life of the dying, it can lead even to a subtle form of Euthanasia. In this context a question posed by John Paul II in 1989 to the Working Group on ‘The Determination of Brain Death and its Relationship to Human Death’ of the Pontifical Academy of Sciences becomes very relevant and begs the attention of Catholic hospitals to reflect and revise their policies on the criteria for ascertaining death as it is a vital procedure in organ donation. “How does one reconcile respect for life – which forbids any action likely to cause or hasten death – with the potential good that results for humanity if the organs of a dead person are removed for transplanting to a sick person who needs them, keeping in mind that the success of such an intervention depends on the speed with which the organs are removed from the donor after his or her death?” Through the years after John Paul II posed the above question, the teachings of the Catholic Church on the issue of the criteria to ascertain death have matured considerably.

Catholic hospitals are to be accountable to the moral teachings of the Church as well as to the law of the land. If the profit motives do not enter for the hospitals and the doctors are committed to Hippocratic Oath, in a country like India, Catholic hospitals have the freedom not to provide services that are against the Church teachings which holds every institution to be accountable to the dignity of human life. This may not be true with Catholic hospitals in countries where government reimburses the services of the hospitals through the taxes of citizens and a Catholic hospital could be the only public hospital in the closest vicinity of the community.

I presume that the Catholic hospitals in India follow the law established by the Government of India in ascertaining the death. Since this law is similar to the UK law that follows the brainstem death criteria rather than entire brain death criteria which is the Church stand on this, some serious moral issues follow.

Let us first examine the law regarding determination of death in India. In India, the Transplantation of Human Organ Bill was introduced in the Lok Sabha on 20th August 1992 and became the Transplantation of Human Organ Act in 1994. This essentially follows the United Kingdom criteria for brainstem death as against the United States criteria. In the US, as per the Uniform Determination of Death Act, irreversible cessation of the entire brain and brainstem function needs to be documented. The United Kingdom criteria for brainstem death permeate in the previously colonized countries while Central and South American countries generally follow the United States position on whole brain death. As per the Transplantation of Human Organ Act of 1994, to make a diagnosis of brainstem death requires a panel of four doctors consisting of the doctor in charge of the patient, the doctor in charge of the hospital where the patient was treated, an independent specialist of unspecified specialty and a neurologist or a neurosurgeon. The burden of proof rests with the specialist of the neurosciences, with the other members confirming the diagnosis. All the four doctors sign each test done to document absence of brainstem function namely pupillary reflex, doll’s head eye movement, corneal reflex (both sides), gag reflex, cough (tracheal), eye movements on caloric testing bilaterally, absence of motor response in any cranial nerve distribution and apnoea test. Reversible causes of coma should be excluded by all possible means namely the absence of any intoxication (alcohol), depressant drugs and neuromuscular blocking agents. Primary hypothermia, hypovolaemic shock and metabolic and endocrine disorders should also be sought for and excluded. Thus in India, it is brainstem death and not brain death which is the legal requirement. EEG is not mandatory nor are other confirmatory tests like cerebral angiography, transcranial Doppler and radionuclide scan. So theoretically it is possible that a patient may be certified ‘deceased’, even though the EEG may be documenting some cortical activity because in India doctors are documenting brainstem death and not whole brain death. Confirmatory tests may however be carried out if the panel of doctors is in doubt or disagreement of the diagnosis.

One of the critical disagreements from the Church position in the above criteria is Church’s insistence for death of entire brain. John Paul II in his address to the 18th International Congress of the Transplantation Society in 2000 defines death of the person as a single event resulted from the separation of the life principle (soul) from the corporeal reality of the person. He further adds that death of the person is an event that no scientific technique or empirical method can identify directly. He agrees that the medical science has developed to the extent of determining death by identifying the biological signs of a dead person. He further acknowledges the shift from the traditional cardio respiratory method to neurological criterion in determining death. Then he adds the most important observation that put the Catholic hospitals in Kerala in trouble: “Specifically, this consists in establishing, according to clearly determined parameters commonly held by international scientific community, the complete and irreversible cessation of all brain activity (in the cerebrum, cerebellum and brain stem). It is only when the cessation of brain activity ceases even in the cerebrum not just in the brain stem, one person loses her integrative capacity.” He then concludes that Church is not an expert in deciding which should be the exact procedures to make sure this criterion is followed. The critical part is that the criterion should be the complete cessation of entire brain. In Catholic hospitals, doctors should take these words of John Paul II seriously: “The criterion adopted in more recent times for ascertaining the fact of death, namely the complete and irreversible cessation of all brain activity, if rigorously applied, does not seem to conflict with the essential elements of sound anthropology.”

As far as the Catholic hospitals are concerned, with its commitment to life even at the most fragile stage, and to avoid any doubts in the minds of the people, it is recommended to follow the brain death criteria rather than brain stem death criteria and to do the confirmatory tests even if it is not asked by the law. There can be a temptation for doctors and hospital managements not to inform the family the difference between stem death and brain death with an objective to fasten the procedure in order to procure the organs. This should be avoided. Along with the tests done for cessation of brain stem, the test for cessation of cerebral functions namely cerebral unreceptively and unresponsivity must be done. Medical circumstances may require the use of confirmatory studies such EEG or blood flow.

In India, a case has been reported in a super specialty hospital where patient was declared brain dead as per the currently accepted standard criteria in India. The confusion arose when a doctor ordered an EEG as a confirmatory test. The EEG showed some cortical activity and when the patient’s relatives showed this EEG to another doctor in another hospital, he opined that that the patient could not be declared brain dead as the EEG was showing cortical activity. The relatives were justifiably confused and angry and sought an explanation for this paradox.

Patients of their families admitted in Catholic hospitals when give consent to a doctor’s decision regarding these delicate issues, do so with the trust that the Catholic Church has expertise in the area to make sure that the doctors in their hospitals do everything with huge respect for human dignity and life. All efforts are to be taken by the hospital managements in consultation with doctors working there to keep this trust intact. The Church has been very active in these bioethical issues ever since medical technology started to make huge contributions in medicine. Every Catholic hospital should form ethics committees and this should serve as a platform for the doctors working in the Catholic hospitals to dialogue with the Church teachings on many ethical issues that are to be dealt in a clinical context. Ethics committees have become powerful tools in the West for hospitals to win back the lost public credibility. In Kerala, Catholic hospitals still command respect in the society. But the times are changing. Medical technology makes huge strides and with it brings many ethical dilemmas that were not heard in the past. Postmodern culture is catching up with the Kerala society and people are becoming more expressive and asking for transparency from all institutions. In such a scenario, the temptation for catholic hospitals can be resting on past laurels. History teaches us that the credibility once lost is lost forever. So Catholic hospitals have to be proactive to have structures in place in order to make sure that they are committed to the health and life of every human being in their richness and fragility across her social, spiritual and physical conditions. Doctors should have the humility to engage in dialogue with the social and moral teachings of the Church which have helped the Church institutions to walk ahead of the times and laws. Hospitals, with the help of ethics committees, should start the tradition of making policies and guidelines regarding delicate bioethical issues that can come up in the hospitals. Even though the clinical expertise of the doctors are to be respected, they should not be left alone while making such huge decisions that can have wide moral implications and credibility of the hospitals. Doctors are the best judges of the clinical situations of the patients. But the moral dilemmas brought in by the newer technology are overwhelming and it is where the rich corpus of Church reflections can be a great aid for doctors.

Catholic hospitals have a duty to proclaim the gospel of life. There is a tendency to do all that law of the land permits in our hospitals. But if a catholic hospital acultures the law without evaluating it against the gospel values, it loses its identity as a Catholic hospital. It is though inculturation rather than acculturation, a Catholic hospital should confront with the law of the land. Practice of the Indian law on neurological criteria to ascertain death in Catholic hospital is a classical example of acculturation of the law.

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