Below is an excerpt from Part 2 of a three-part article “A Search for Wholeness: An Orthodox Response to Organ Donation and Retrieval” written by Matushka Linda Korz, M.D. and published in Orthodox Canada: A Journal of Orthodox Christianity. You can read all three parts of the article here, here and here. I highly recommend reading it, whether you are considering organ donation or working in an environment in which you must play some part in organ retrieval, Matushka’s article is very enlightening.
WHEN DOES DEATH OCCUR?
Some will argue that the greatest gift one can offer is to give ones life for another. Surely the Church teaches that, doesn’t it? The Lord Himself tells us, “Greater love has no man than this, that a man lay down his life for his friends.“(John 15:13) But does this apply to the state of organ retrieval at the present time? Does the harvesting of organs from one individual at the point of death as it currently occurs in North American hospitals, constitute a sacrifice to save life, or a sin that takes a life?
Currently, in Canada and the United States of America there are two legal definitions of death: the traditional definition of death, irreversible cessation of circulatory and respiratory functions (cardiac death) or cessation of the brain whether as a whole or in part (neurological determination of death, NDD or brain death). In 1971, the historic ad hoc committee of the Harvard Medical School presented its report on the definition of Brain Death and described scientific and medical criteria on which to base the diagnosis. This landmark paper opened the door for legislation to sanction the removal and use of organs for transplantation from patients who did not fit the medical criteria for cardiac death, but were found to have severe irreversible brain injuries leading to a state of prolonged coma. These patients were successfully resuscitated and kept alive by advances in circulatory medicine and mechanical ventilation.
It was expedient that a more liberal and utilitarian definition of death be ethically, morally, and, more importantly legally, accepted. “Brain death has proved to be a most important concept for the progress of organ transplantation…. In parts of the world where brain death was given legal standing and became standard practice, vital organ transplantation increased rapidly.” During the process of brain death donations, the duration of oxygen deprivation (known in medical literature as warm ischemic time) and the extent of loss of viable cells in the body are minimized since the heart continues to perfuse and nourish the tissues while mechanical ventilation sustains breathing (recently, the more descriptive term of heart-beating donation is preferred). In North America and most parts of Europe, organ retrieval from NDD individuals is by far the leading source of all organs for transplantation.
Over three decades later, there is still disagreement worldwide regarding the definition of brain death and, unsurprisingly, how to diagnosis it. Henry Beecher, chairman of the historic ad hoc committee of the Harvard Medical School to examine the definition of Brain Death stated:
“At whatever level we choose to call death, it is an arbitrary decision. Death of the heart? The hair still grows. Death of the brain? The heart may still beat. The need is to choose an irreversible state where the brain no longer functions. It is best to choose a level where, although the brain is dead, usefulness of other organs is still present. This, we have tried to make clear in what we have called the new definition of death(…). Here we arbitrarily accept as death, the destruction of one part of the body; but it is the supreme part, the brain…”
How much of the brain? Current tests only look at selective parts of the brain, whether it be brain stem or higher cognitive function, and thus, by definition, these tests can not confirm the death of the whole brain.
In a recent issue of a leading Canadian medical journal the authors concluded: “the current evidence base for existing NDD (neurologic determination of death) guidelines is inadequate … . We recommend that after NDD, the patient be declared dead.” Father John Breck, an Orthodox author on bioethics, clearly outlines the problem in regard to the state of organ donation throughout the world today:
“Using brain-stem criteria to determine death, we are left with the gruesome fact that vital organs can only be harvested from patients who are technically still alive… Human personhood is determined not by medical diagnosis but by divine Providence.”
The acceptance of brain death whether legally or morally is not equal or universal among countries. In India, organ transplants are largely limited to live or cadaveric donations due to religious and cultural rejection of NDD. In Japan, heart transplants were not done until 1997 when government legislation finally permit organ donation after neurologic or brain death. Despite these realities, and despite the growing challenge within the scientific community to acknowledge that biological death cannot be proven with certainty in brain death, information given to families and patients about organ procurement continues to falsely represent brain death as physical death. Furthermore, in some cases, religious and cultural consent to organ retrieval after neurologic death is misrepresented and misleading. John Gillman, pastor and ethicist in California, in his article titled Religious Prospectives on Organ Donation attempts to outline the Christian prospective. The statement that the Greek Orthodox do not oppose organ donation was subsequently reinterpreted by the Trillium Gift of Life Network (an agency created in 2000 by the Government of Ontario, Canada) as the Greek Orthodox Churchs support organ donation. (see www.Giftoflife.on.ca)
For Orthodox Christians, the supreme part of the body is not the brain (which is an Aristotelian notion; c.f. De Anima) but the heart. “The heart is not just a physical organ or centre of his psychic life but something indefinable yet capable of being in contact with God, the Source of all being.” In the Book of the prophet Isaiah, we read, “make the heart of this people fat. Make their ears heavy, and shut their eyes; lest they see with their eyes, and hear with their ears, and understand with their heart, and turn again, and be healed.”(Isaiah 6:10) Later, in another passage, “these people draw near to Me with their mouth, And honour Me with their lips, But their heart is far from Me. And in vain they worship Me, Teaching as doctrines the commandments of men.” (Isaiah 29:13) Christ tells us, “Where your treasure is, there will your heart be also.” (Matthew 6:21).
The reality that the noetic heart is located within the physical heart has always been the teaching of the Orthodox Church. St. Gregory Palamas (1296-1359), a champion of the Orthodox understanding of the knowledge of God, writes:
“Since our soul is a single entity possessing many powers, it utilizes as an organ the body that nature lives in conjunction with it. What organs, then, does the power of the soul that we call ‘intellect’ make use of when it is active?… For some locate it in the head, as though in a sort of acropolis; others consider that its vehicle is the centremost part of the heart, that aspect of the heart that intelligence is neither within us as in a container – for it is incorporeal – nor yet outside us, for it is united to us; but it is located in the heart as in its own organ.”
St. Nicodemos the Hagiorite (1749-1808) on instruction for stillness in prayer writes:
“You must free the energy (energeia) of your mind, whose organ is the brain, form all the external things of the world, through the guarding of the senses and of the imagination. Then you must bring the energy into the heart, which is the organ of the essence (ousia) of the mind. This return is customarily brought about in the case of beginners – as the Divine Wakeful Fathers teach – by turning the head down and resting the chin on the chest.”
Secular man, having lost the quietness and gentleness of heart, can not know God. “Blessed are the pure in heart, For they shall see God.”(Matthew 5:8) As a consequence, he finds incredulous the Truth of self knowledge, the essence of the soul is located within the physical heart. Thus, ignorant of the mystery of life, how can he define the mystery of death and more specifically, how can the definition of death be measured by some grotesque notion of cessation of some part of the brain?
It is sad but not surprising that, for the most part, the medical community does not truly understand the nature of death. Acknowledging this limitation, Zameretti et al. advocate the substitution of the word (and thus concept of) death with the term irreversible coma or more precisely, irreversible apnoeic coma, understood not as equivalent to death, but as describing a particular condition in which life support should be legitimately forgone and organs can be retrieved from consenting patients. Even more pathetic is the disregard, at best, and denial at worst that the human person is a creation of body and soul. So long as the medical community is ignorant of the soul of an individual, the medical definition of death will never be complete. Organ retrieval will remain an act of taking life, since it concentrates only on questions of physiology, ignoring the relationship between the soul and the body. Saint Paul cautions, that “those who live according to the flesh set their minds on the things of the flesh.” (Romans 8:5) For Orthodox Christians, death is simply an impermanent separation of body and soul which afflicts mankind until the final judgement. Saint John of Damascus reminds us, that “truly most terrible is the mystery of death, how the soul is violently parted from the body, from the harmony, and most natural bond of kinship is cut off by the divine will.”
 Nereo Zamperetti et. al. Irreversible apnoeic coma 35 years later: Towards a more rigorous definition of brain death? Intensive Care Med 2004; 30(9):1715-22.
 John Gillman. Death and organ procurement: public beliefs and attitudes. Kennedy Institute Ethics J 2004; 14(3):217-34.
 Brain arrest: the neurological determination of death and organ donor management in Canada. CMAJ 2006; 174(6): Supplemental S1-30.