Death has become a commodity. That was the considered opinion of a participant at a conference on bioethics in Pune on the weekend. As many medical professionals have observed, there is an increasing trend in modern medicine of postponing death with the help of artificial life support.
That is why it is imperative for India to develop a uniform definition of death and a standard method for a doctor to declare a person dead, said Dr Sunil Shroff, the managing trustee of Mohan Foundation, a non-profit organisation working for improving cadaver organ donations in India. Speaking at the conference organised by the Indian Journal of Medical Ethics, Shroff noted, “Many doctors call it ‘life support’ giving a wrong impression to the patient’s relatives.”
Currently, death is defined “permanent disappearance of all evidence of life at any time after live-birth has taken place” under the Registration of Births and Deaths Act. Another definition of death, acknowledged in the Human Organ Transplantation, Act is “brain stem death”, the “stage at which all functions of the brain-stem have permanently and irreversibly ceased.”
But, as Shroff told his audience, there is still a divide in declaring brain death and cardiopulmonary death. As a result, diagnosing death is as challenging as diagnosing disease.
After his lecture, Shroff spoke to Scroll.in about the challenges of declaring brain death in India and how this impacts organ donations.
What is the difference between brain death and natural death?
A brain death in India is when a person develops irreversible damage to the brain stem. This results in irreversible loss of our consciousness and breathing capacity. Head injury leading to brain hemorrhage due to road traffic accident is the commonest cause of brain death. Meanwhile, a cardiopulmonary death is irreversible loss of the function of the heart and lungs.
Why are doctors and hospitals in India scared of declaring brain death?
They are not so much scared but a little indifferent. Also the process of certification is cumbersome as it requires four doctors to certify twice at six hours apart. Also the problem is that brain death is linked to organ donation so if there is no talk of organ donation they will not certify brain death. Some have also never conducted this test so lack the skills.
There are also several hospitals and doctors who would not like to be associated with the concept of cadaver organ donation because of the stigma associated with kidney donation. “Kidney donation” today in our society is used in derogatory fashion due to scandals and kidney commerce that keeps being reported in the media. So, doctors feel that if they indulge in the business of kidney or organ donation, the name of their hospitals will be tarnished.
What is the solution to improve declaration of brain deaths in intensive care units?
We first need to promote organ donation concept among our doctors and medical students. All intensive care units doctors too will need to be trained on how to conduct brain death test. Delinking brain death from organ donations will also help. Brain death testing should become a routine practice in the intensive care unit. At least this way we will be able to identify potential organ donors. If there is no organ donation only one doctor should be required to declare it. The death certificate should also have the option where brain death is accepted form of death.
Does that mean that patients dying of brain death are only declared dead when there is eventually cardiopulmonary death?
When a patient is declared brain dead and his organs are to be donated there is no debate about switching off the artificial support such as the ventilator. The problem arises when the relatives refuse organ donation.
Once the person is declared brain dead, his support should be withdrawn but if the family does not agree problem starts as the hospital bill will go up and you are unnecessarily continuing to have an ICU bed occupied. Some relatives will see that the heart is still beating and think that their loved one is still alive.
They may also accuse doctors saying that because they agreed to donate organs the doctors will continue supporting till the organs are removed, but if they refuse the doctors will withdraw life support. It creates unnecessary tension.
This is why we require uniform declaration of death. The United States already has legislation on a similar line. We have been pushing for a new legislation or an amendment in the existing Acts to allow doctors to declare brain deaths just like they would declare a cardiopulmonary death and delink it with organ donation.
What is the point in keeping somebody who is dead on the ventilator support?
In a country like ours where health facilities are scarce, freeing of ventilators is important especially in a public health setting. It is wrong to continue artificial support just because the patient’s relatives can afford it.