Quantum Ethics: Schrödinger’s Cat & Donation after Cardiac Death
Recent discussions of transplanting hearts from so-called DCD (Donation after Cardiac Death) patients into others (for example the recent Baby Kaylee saga at Toronto’s Hospital for Sick Children) raise serious questions that seem to only have explainable answers in the field of quantum physics. I don’t know if physicist Erwin Schrödinger actually had a living, breathing cat but the hypothetical cat that he proposed to illustrate a paradox back in 1935 to illustrate a paradox has certainly achieved fame.
The paradox that Schrödinger’s hypothetical cat presented was that the cat was simultaneously dead and alive. Schrödinger asked Einstein to imagine that a cat was inside a box and that we could not see or hear or otherwise sense what was happening inside the box. The cats fate is linked to some random event inside the box. Applying the rules of quantum physics the cat is both dead and alive until we can open the box and and directly determine its state. Common sense would suggest that surely the cat is either dead or alive inside the box, whether we know it or not, but applying the rules of quantum physics, the actual state does not come into being until the moment that we measure it. Of course, Schrödinger didn’t actually believe that; he thought the idea made no sense. His real goal was to point out that if this was dumb idea when applied to cats, it might be just as dumb an idea to apply to subatomic particles.
Now, in the 21st century, we appear to applying a Schrödinger’s cat logic to the ethics of organ donation. Here is how it works. A cardinal rule (called the Dead Donor Rule) of organ donation is that vital organs (those necessary for life) cannot be harvested from living donors, since doing so amounts to killing the donor. Our notion of brain death was primarily constructed and accepted a few decades ago, when the Ad Hoc Committee of Harvard Medical School determined “the irreversible cessation of all brain function” amounted to death and allowed harvesting organs from people who did not meet the traditional criterion for death. More recently there has been a move expand the definition of death to include donation after cardiac death (DCD) in the case of potential donors who do not meet the criteria for brain death.
The notion of cardiac death seems simple. If your heart is irreversibly stopped, you are dead, and organ donation can proceed without waiting for brain death which might take some additional time and render the harvested organs useless or less viable. In order to be sure that the heart stoppage is truly irreversible, the patient is not pronounced dead until a specified period of time has passed. This amount of time is variously set at 2, 5, or 10 minutes. The guidelines generally used here in Canada were published in October 2006 and say:
The legal time of death is the determination after a 5- minute observation period.
The purpose of the 5-minute observation period is to confirm the irreversibility of cardiocirculatory arrest before organ procurement.
So logically, the patient is dead because of irreversible stoppage of the heart. This might be of great use in harvesting a number of organs for needy recipients. It would seem obvious, however, that the one organ that we should not transplant into another human being is a heart that is irreversibly stopped, since this would be no better and almost certainly worse than the damaged heart that the recipient is trying to replace.
So it seems fairly obvious that a recipient could only benefit from a heart that is not irreversibly stopped but a donor can only donate a heart that is irreversibly stopped, because if the heart has not stopped irreversibly and the donor is not brain dead, the donor is still alive and taking the heart from a living person would cause them to die, which violates the dead-donor rule, as well the criminal code, which frowns on killing people.
It also might be pointed out that to most of us, irreversible is a fairly unambiguous term. The Oxford English Dictionary provides two meanings:
1. That cannot be undone, repealed, or annulled; unalterable, irrevocable.
2. That cannot be turned backwards, upside down, or in the opposite direction.
That seems fairly clear.
Like Schrödinger’s cat, the donation-after-cardiac-death heart donor by definition must be simultaneously dead and alive. The donor must be dead in order to donate the heart but can be considered dead only if the heart is irreversibly stopped, but the heart is not irreversibly stopped if it functions in the transplant recipient. Once the heart begins to function again the fiction of irreversibility is exposed and condition for the previous pronouncement of death is violated.
Of course, I am not the first to point out this paradox. Esteemed ethicist, Robert Veatch, writing in the New England Journal of Medicine (2008) points out:
Virtually all observers have assumed that donation after cardiac death could, in principle, provide any vital organs except hearts. If someone is pronounced dead on the basis of irreversible loss of heart function, after all, it would not be possible for heart function to be restored in another body. Some have suggested defining death as the impossibility of autoresuscitation, which means that the heart cannot restart spontaneously even if it could be started by means of external stimulation. Calling such a heart “irreversibly stopped” may be defensible if no attempt will be made to restart the heart. However, one cannot say a heart is irreversibly stopped if, in fact, it will be restarted.
[and]
The practice of donation after cardiac death has gained some acceptance, but only for organs other than hearts. There are controversial implications, however, if the goal is to transplant a heart after cardiac death. It is impossible to transplant a heart successfully after irreversible stoppage: if a heart is restarted, the person from whom it was taken cannot have been dead according to cardiac criteria. Removing organs from a patient whose heart not only can be restarted, but also has been or will be restarted in another body, is ending a life by organ removal. Of course, it would still be possible to pronounce such patients dead if they met the criteria for brain death, but according to this logic, it would simply not be possible to perform successful heart transplantation in a manner consistent with the dead donor rule after death pronounced on the basis of cardiac criteria.
Quoted in the Washington Post (14 August 2008), Veatch seems even more direct:
The whole issue is whether the infants from whom the hearts were taken were dead. It seems very clear to me that they were not. I think it’s illegal, and if it’s illegal, what we’re talking about is the physicians causing the death of the three patients, and that would be homicide. It’s immoral. I think it should be stopped.
James Burdick of the Department of Health and Human Services dismisses Veatch’s concerns as “fussy semantics, but it might well be countered that the donation of heart after cardiac death depends on “fuzzy semantics.”
As long as most people see the practice as a net benefit, ethicists as well as surgeons will stretch meanings and logic to permit the practice. There is no question that getting a heart benefits the recipients, so we are left with the question of whether the practice harms the donors. Of course, it kills them. Once their hearts are removed, they are dead and this is becomes irreversible almost immediately.
Two arguments might be made that they are not harmed as a result of killing them: (1) rapid death would ensue in spite of our best efforts so that there is no appreciable shortening of life as a result of the killing, or (2) the quality of the donor’s existence is so poor that he or she is better off or at least no worse off being dead. In a sense, this argument suggest that killing the donor is justified because it will save the life of the recipient which is more valuable than the life of the donor.
Such arguments cannot be made explicitly because of they are clearly illegal, blatantly disrespectful, and defy the dead-donor rule. Nevertheless, I believe that they are implicitly the real force behind this practice. Is it merely coincidental that the donation-after-cardiac-death donors are almost always, if not always, severely cognitively impaired or labelled as severely cognitively impaired? Has anyone ever transplanted the heart of donation-after-cardiac-death donor who is not severely cognitively impaired into a recipient who is severely cognitively impaired? If so, I would be delighted to hear about it.
Many years ago, in defending the hospitals transplant of a healthy baboon’s heart into a human child, David Larson, co-director of the Center for Christian Ethics at Loma Linda University, has quoted as saying,
If a primate’s capability was higher than a human’s—say a severely mentally handicapped child’s—I think it would be appropriate to support the opposite approach . . . a transplant from a [severely mentally handicapped] child to save the life of a healthy baboon.
So, perhaps the real issue is not whether the donor is already dead or is killed in the process. The real issue is whether anyone cares if he or she is killed, and if the donor has or is thought to have a severe cognitive impairment, no one seems to care very much about the details. In my view, this is the heart of the matter.
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The distinction between the state of the dying person and the state of the transplant recipient is clear. The window where someone can be saved once they begin the process of cardiac death is fairly short, and if nothing can be done within that window, the person is dead. While technically something could be done to reverse the condition, reality prevents it from being done within that window. Conceivably as medicine advances, that may change and this apparent paradox may go away as we are able to treat people in increasingly short periods of time.
The transplant recipient, however, has not crossed into that window.
The other apparent contradiction here is, why would an apparently damaged organ be transplanted to a person needing a healthy one?
But the fact is that there are many causes of cardiac death…the patient dies when the heart is not able to adequately supply the body with blood, but that does not necessarily mean the heart itself is damaged. Ventricular fibrillation is a good example of this. This often accompanies a heart-attack when the lack of blood supply to the heart muscle induces uncoordinated and ineffective heart contraction. However, at this time, while the arteries supplying the heart muscle are seriously compromised, the heart muscle itself may not have been damaged. If harvested quickly enough, the heart may be completely viable for transplant. The transplant recipient may have a completely healthy cardiac vascular system, and therefore would not have the same risk of heart attack as the unfortunate donor.
Admittedly, individual’s vary. In theory there could be problems elsewhere in the circulatory system (e.g., extreme pulmonary hypertension) In actual practice, however, I have never heard of such a case. In most cases, the only reality that prevents the heart from being restarted within the window of opportunity in the donor is the choice that it is not going to be restarted. The only cases that I have heard reported of heart donation after cardiac death in infants is when the donor infant’s hear is deliberately stopped via anoxia, the infant is declared dead, the heart is cooled in situ, harvested, and transplanted. Can you give actual, not hypothetical, examples of other cases with different circumstances?
As you mentioned, Dr. Sobsey, I think that brain death is more often being used today as the criterion for death, rather than cardiac death. This is probably because it actually makes it easier to do organ transplantation on the heart-if you can prove someone is brain dead, then you don’t have to get in the whole quandary of having a heart that is alive and dead at the same time.
Your comment about severe cognitive impairment was surprising to me, however. Is there any evidence that those who are more severely cognitively impaired are more likely to have their hearts removed than those who are not cognitively impaired? If this is true, it would seem like a rather gross breach of justice.