In the Address of John Paul II below, you will find the designation of brain death as the sign that is purported to give “moral certainty” that a person has, indeed, died. Death is understood in this papal address as “the total disintegration of that unitary and integrated whole that is the personal self.” Brain death as criterion “for ascertaining death used by medicine today should not be understood as the technical-scientific determination of the exact moment of a person’s death, but as a scientifically secure means of identifying the biological signs that a person has indeed died.”
The decisive center of the papal address is the supposition that the scientific community has ascertained that “the total disintegration of that unitary and integrated whole that is the personal self” takes place when there is “the complete and irreversible cessation of all brain activity (in the cerebrum, cerebellum and brain stem). This is then considered the sign that the individual organism has lost its integrative capacity.”
In a word, the irreversible cessation of all brain activity signifies that the body no longer has the ability to be an integrated organism. The previous posting of Dr. Alan Shewmon purports to clinically show the exact opposite. And since “the Church does not make technical decisions,” it is important for every informed mind to be open to the clinical facts concerning the relation between complete and irreversible “brain death” and the somatic integration as organism. The latter is the undisputed “sign” of “that unitary and integrated whole that is the personal self.”
ADDRESS OF THE HOLY FATHER JOHN PAUL II TO THE 18th INTERNATIONAL CONGRESS OF THE TRANSPLANTATION SOCIETY
Tuesday 29 August 2000
Distinguished Ladies and Gentlemen,
1. I am happy to greet all of you at this International Congress, which has brought you together for a reflection on the complex and delicate theme of transplants. I thank Professor Raffaello Cortesini and Professor Oscar Salvatierra for their kind words, and I extend a special greeting to the Italian Authorities present.
To all of you I express my gratitude for your kind invitation to take part in this meeting and I very much appreciate the serious consideration you are giving to the moral teaching of the Church. With respect for science and being attentive above all to the law of God, the Church has no other aim but the integral good of the human person.
Transplants are a great step forward in science's service of man, and not a few people today owe their lives to an organ transplant. Increasingly, the technique of transplants has proven to be a valid means of attaining the primary goal of all medicine - the service of human life. That is why in the Encyclical Letter Evangelium Vitae I suggested that one way of nurturing a genuine culture of life "is the donation of organs, performed in an ethically acceptable manner, with a view to offering a chance of health and even of life itself to the sick who sometimes have no other hope" (No. 86).
2.As with all human advancement, this particular field of medical science, for all the hope of health and life it offers to many, also presents certain critical issues that need to be examined in the light of a discerning anthropological and ethical reflection.
In this area of medical science too the fundamental criterion must be the defence and promotion of the integral good of the human person, in keeping with that unique dignity which is ours by virtue of our humanity. Consequently, it is evident that every medical procedure performed on the human person is subject to limits: not just the limits of what it is technically possible, but also limits determined by respect for human nature itself, understood in its fullness: "what is technically possible is not for that reason alone morally admissible" (Congregation for the Doctrine of the Faith, Donum Vitae, 4).
3. It must first be emphasized, as I observed on another occasion, that every organ transplant has its source in a decision of great ethical value: "the decision to offer without reward a part of one's own body for the health and well-being of another person" (Address to the Participants in a Congress on Organ Transplants, 20 June 1991, No. 3). Here precisely lies the nobility of the gesture, a gesture which is a genuine act of love. It is not just a matter of giving away something that belongs to us but of giving something of ourselves, for "by virtue of its substantial union with a spiritual soul, the human body cannot be considered as a mere complex of tissues, organs and functions . . . rather it is a constitutive part of the person who manifests and expresses himself through it" (Congregation for the Doctrine of the Faith, Donum Vitae, 3).
Accordingly, any procedure which tends to commercialize human organs or to consider them as items of exchange or trade must be considered morally unacceptable, because to use the body as an "object" is to violate the dignity of the human person.
This first point has an immediate consequence of great ethical import: the need for informed consent. The human "authenticity" of such a decisive gesture requires that individuals be properly informed about the processes involved, in order to be in a position to consent or decline in a free and conscientious manner. The consent of relatives has its own ethical validity in the absence of a decision on the part of the donor. Naturally, an analogous consent should be given by the recipients of donated organs.
4. Acknowledgement of the unique dignity of the human person has a further underlying consequence: vital organs which occur singly in the body can be removed only after death, that is from the body of someone who is certainly dead. This requirement is self-evident, since to act otherwise would mean intentionally to cause the death of the donor in disposing of his organs. This gives rise to one of the most debated issues in contemporary bioethics, as well as to serious concerns in the minds of ordinary people. I refer to the problem of ascertaining the fact of death. When can a person be considered dead with complete certainty?
In this regard, it is helpful to recall that the death of the person is a single event, consisting in the total disintegration of that unitary and integrated whole that is the personal self. It results from the separation of the life-principle (or soul) from the corporal reality of the person. The death of the person, understood in this primary sense, is an event which no scientific technique or empirical method can identify directly.
Yet human experience shows that once death occurs certain biological signs inevitably follow, which medicine has learnt to recognize with increasing precision. In this sense, the "criteria" for ascertaining death used by medicine today should not be understood as the technical-scientific determination of the exact moment of a person's death, but as a scientifically secure means of identifying the biological signs that a person has indeed died.
5. It is a well-known fact that for some time certain scientific approaches to ascertaining death have shifted the emphasis from the traditional cardio-respiratory signs to the so-called "neurological" criterion. Specifically, this consists in establishing, according to clearly determined parameters commonly held by the international scientific community, the complete and irreversible cessation of all brain activity (in the cerebrum, cerebellum and brain stem). This is then considered the sign that the individual organism has lost its integrative capacity. [This is the point of contention with regard to the findings of Dr. Shewmon]
With regard to the parameters used today for ascertaining death - whether the "encephalic" signs or the more traditional cardio-respiratory signs - the Church does not make technical decisions. She limits herself to the Gospel duty of comparing the data offered by medical science with the Christian understanding of the unity of the person, bringing out the similarities and the possible conflicts capable of endangering respect for human dignity.
Here it can be said that 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 a sound anthropology. Therefore a health-worker professionally responsible for ascertaining death can use these criteria in each individual case as the basis for arriving at that degree of assurance in ethical judgement which moral teaching describes as "moral certainty". This moral certainty is considered the necessary and sufficient basis for an ethically correct course of action. Only where such certainty exists, and where informed consent has already been given by the donor or the donor's legitimate representatives, is it morally right to initiate the technical procedures required for the removal of organs for transplant.
6. Another question of great ethical significance is that of the allocation of donated organs through waiting-lists and the assignment of priorities. Despite efforts to promote the practice of organ-donation, the resources available in many countries are currently insufficient to meet medical needs. Hence there is a need to compile waiting-lists for transplants on the basis of clear and properly reasoned criteria.
From the moral standpoint, an obvious principle of justice requires that the criteria for assigning donated organs should in no way be "discriminatory" (i.e. based on age, sex, race, religion, social standing, etc.) or "utilitarian" (i.e. based on work capacity, social usefulness, etc.). Instead, in determining who should have precedence in receiving an organ, judgements should be made on the basis of immunological and clinical factors.Any other criterion would prove wholly arbitrary and subjective, and would fail to recognize the intrinsic value of each human person as such, a value that is independent of any external circumstances.
7. A final issue concerns a possible alternative solution to the problem of finding human organs for transplantion, something still very much in the experimental stage, namely xenotransplants, that is, organ transplants from other animal species.
It is not my intention to explore in detail the problems connected with this form of intervention. I would merely recall that already in 1956 Pope Pius XII raised the question of their legitimacy. He did so when commenting on the scientific possibility, then being presaged, of transplanting animal corneas to humans. His response is still enlightening for us today: in principle, he stated, for a xenotransplant to be licit, the transplanted organ must not impair the integrity of the psychological or genetic identity of the person receiving it; and there must also be a proven biological possibility that the transplant will be successful and will not expose the recipient to inordinate risk (cf. Address to the Italian Association of Cornea Donors and to Clinical Oculists and Legal Medical Practitioners, 14 May 1956).
8. In concluding, I express the hope that, thanks to the work of so many generous and highly-trained people, scientific and technological research in the field of transplants will continue to progress, and extend to experimentation with new therapies which can replace organ transplants, as some recent developments in prosthetics seem to promise. In any event, methods that fail to respect the dignity and value of the person must always be avoided. I am thinking in particular of attempts at human cloning with a view to obtaining organs for transplants: these techniques, insofar as they involve the manipulation and destruction of human embryos, are not morally acceptable, even when their proposed goal is good in itself. Science itself points to other forms of therapeutic intervention which would not involve cloning or the use of embryonic cells, but rather would make use of stem cells taken from adults. This is the direction that research must follow if it wishes to respect the dignity of each and every human being, even at the embryonic stage.
In addressing these varied issues, the contribution of philosophers and theologians is important. Their careful and competent reflection on the ethical problems associated with transplant therapy can help to clarify the criteria for assessing what kinds of transplants are morally acceptable and under what conditions, especially with regard to the protection of each individual's personal identity.
I am confident that social, political and educational leaders will renew their commitment to fostering a genuine culture of generosity and solidarity. There is a need to instil in people's hearts, especially in the hearts of the young, a genuine and deep appreciation of the need for brotherly love, a love that can find expression in the decision to become an organ donor.
May the Lord sustain each one of you in your work, and guide you in the service of authentic human progress. I accompany this wish with my Blessing.
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