In the Absence of the Sacred Part 3

Jerry Mander

While planning to write these two books, however, it became apparent to me that their subjects were inseparable. They belonged together as one book. There is no way to understand the situation of Indians, Eskimos, Aborigines, island peoples, or other native societies without understanding the outside societies that act upon them. And there is no way to understand the outside societies without understanding their relationships to native peoples and to nature itself.

All things considered, it may be the central assumption of technological society that there is virtue in overpowering nature and native peoples. The Indian problem today, as it always has been, is directly related to the needs of technological societies to find and obtain remotely located resources, in order to fuel an incessant and intrinsic demand for growth and technological fulfilment. The process began in our country hundreds of years ago when we wanted land and gold. Today it continues because we want coal, oil, uranium, fish, and more land. As we survey the rest of the world - whether it is the Canadian Arctic, the Borneo jungle, or the Brazilian rainforest - the same interaction is taking place for the same reasons, often involving the same institutions.

All of these acts were and are made possible by one fundamental rationalization: that our society represents the ultimate expression of evolution, its final flowering. It is this attitude, and its corresponding belief that native societies represent an earlier, lower form on the evolutionary ladder, upon which we occupy the highest rung, that seem to unify all modern political perspectives: Right, Left, Capitalist, and Marxist.

Save for such nascent movements as bioregionalism and Green politics, which have at least questioned the assumptions underlying this attitude, most people in Western society are in agreement about our common superiority. So it becomes okay to humiliate - to find insignificant and thus subject to sacrifice - any way of life or way of thinking that stands in the way of a kind of "progress" we have invented, which is scarcely a century old. In fact, having assumed such superiority, it becomes more than acceptable for us to bulldoze nature and native societies. To do so actually becomes desirable, inevitable, and possibly "divine."

But the assertion that technological society is something higher than what came before, and that it is bound to bring us a better world, has lately fallen open to grave doubts. The Industrial Revolution is about a century old, and we have had ample time to draw a few conclusions about how it is going. It is not too soon to observe that this revolution may not be living up to its advertising, at least in terms of human contentment, fulfilment, health, sanity, and peace. And it is surely creating terrible and possibly catastrophic impacts on the earth. Technotopia seems already to have failed, but meanwhile it continues to lurch forward, expanding its reach and becoming more arrogant and dangerous.

The next questions become: Can we expect the situation to improve or worsen in the future? And what of the people who always told us that this way would not work, and continue to say so now? Finally, which is the more "romantic" viewpoint: that technology will fix itself and lead us to paradise, or that the answer is something simpler?

Jerry Mander, In the Absence of the Sacred, Sierra Club Books, (1992) p2-7.

COMMMENT: The following texts trace the 20th century questioning of the necessity "to bulldoze nature and native societies" in the name of technological progress.

 

In the Absence of the Sacred Part 2

Jerry Mander

The second book was to be a kind of continuation and update of Dee Brown's Bury My Heart at Wounded Knee: An Indian History of the American West. That book impressed me tremendously when I read it twenty years ago. In one sense it was a masterful work, detailing in excruciating fashion U.S. double-dealing and brutality against the Indians. But in another sense Brown did the Indian cause a disservice by seeming to suggest that they were all wiped out, and that now there is nothing to be done. The book put the reader through an emotional catharsis; having read it, it was as if one had already paid one's dues. Combined with the popular imagery from television and films, the book helped remand Indian issues to the past.

Even liberal-minded people, concerned about issues of justice, who acknowledge the atrocities committed on this land, tend to speak of Indian issues as tragedies of the distant past. So ingrained is this position that when, occasionally, non-Indians do come forward on behalf of present-day Indian causes - Marlon Brando, William Kunstler, Robert Redford, Kevin Costner, Jane Fonda - they are all put into that "romantic" category. People are a bit embarrassed for them, as if they'd stepped over some boundary of propriety. When environmentalists such as David Brower occasionally speak publicly about how we should heed the philosophies of the Inuit (Eskimos), they are thought impractical, uncool, not politic, not team players. (And when a specific issue pits native traditions against some current environmental concern, such as fur trapping, or subsistence sealing, or whaling, the native viewpoint is not given a fair hearing.) Literary luminaries like Peter Matthiessen have also been chastised for books on contemporary Indian issues (In the Spirit of Crazy Horse and Indian Country), with the implication that they should return to novels and Zen explorations.

I have had my own experiences with this. In Four Arguments I reported several encounters with Indians as a way of revealing bias in the media. I was surprised at the number of critics who cited those lines as foolish. Gene Youngblood, for example, a respected radical writer on media issues, said, "Mander is so naive. . . . My God, that old sixties chestnut, the Indians."

I thought that even Nelson Mandela got that treatment when he spoke about Indians at his 1990 Oakland rally. The news reports seemed to suggest that he didn't quite understand "our Indians."

The Indian issue is not part of the distant past. Many of the worst anti - Indian campaigns were undertaken scarcely 80 to 100 years ago. Your great-grandparents were already alive at the time. The Model-T Ford was on the road.

More to the point is that the assaults continue today. While the Custer period of direct military action against Indians may be over in the United States, more subtle though equally devastating "legalistic" manipulations continue to separate Indians from their land and their sovereignly, as we will see from the horrible events in Alaska, described in Chapter 16.

There are still over one and a half million Indians in the United States today. Significant numbers of them continue to live in wilderness and desert regions and in the far north of Alaska, often engaging in traditional subsistence practices on the same lands where their ancestors lived for millennia. Contrary to popular assumptions, most of these Indians are not eager to become Americans, despite the economic, cultural, and legal pressures to do so.

Elsewhere in the world, millions of native peoples also live in a traditional manner, while suffering varying degrees of impact from the expansion of Western technological society. In places such as Indonesia, Borneo, New Guinea, the Amazon forests, Bolivia, Peru, Ecuador, Guatemala, parts of central Africa, the north of Canada, and even Scandinavia, the Soviet Union, China, and Tibet, tribal peoples are struggling to defend their ancestral lands. In other places, such as India, Iraq, Turkey, Mexico, Chile, the Pacific islands, New Zealand, and Australia, millions more native peoples live a kind of in-between existence, while they are under cultural, economic, or military siege.

According to Cultural Survival, the Boston-based human rights organization, there are at least 3,000 native nations in the world today that continue to function within the boundaries of the 200-odd countries that assert sovereignty over them. Many wars that our media describe as "civil wars" or "guerrilla insurgencies" are actually attempts by tribal nations to free themselves of the domination of larger nation-states. In Guatemala, it's the Mayans. In Burma, it's the Karens. In the Amazon, it's the Yanomamo and the Xingu, among others. In Micronesia, it's the Belauans. In Indonesia, it's the peoples of Irian Jaya.

Perhaps the most painful realization for Americans is that in many of these foreign locales - particularly South America, the Pacific islands, Indonesia, and the Philippines - the natives' struggles to maintain their lands and sovereignty is often directed against United States corporations, or technology, or military. More to the point, it is directed against a mentality, and an approach to the planet and to the human place on Earth, that native people find fatally flawed. For all the centuries they've been in contact with us, they've been saying that our outlook is missing something. But we have ignored what they say. To have heeded them would have meant stopping what we were doing and seeking another path. It is this very difference in world views that has made the assault on Indian people inevitable.

    Jerry Mander, In the Absence of the Sacred, Sierra Club Books, (1992) p2-7.

COMMENT: Bury My Heart at Wounded Knee is emotionally draining, yet it demands to be studied alongside accounts of the fate of indigenous peoples today, such as those by Jay Griffiths.

In the Absence of the Sacred Part 1

 Extracts from In the Absence of the Sacred, by Jerry Mander

Originally I planned to write two books. The first was to be a critique of technological society as we know it in the United States, a kind of sequel to Four Arguments for the Elimination of Television. Instead of concentrating on TV, though, it would have focused on the new technological age: "the information, society," computerization, robotization, space travel, artificial intelligence, genetics, satellite communications. This seemed timely, since these technologies are changing our world at an astoundingly accelerating rate. Thus far, most people view these changes as good. But are they?

That our society would tend to view new technologies favorably is understandable. The first waves of news concerning any technical innovation are invariably positive and optimistic. That's because, in our society, the information is purveyed by those who stand to gain from our acceptance of it: corporations and their retainers in the government and scientific communities. None is motivated to report the negative sides of new technologies, so the public gets its first insights and expectations from sources that are clearly biased.

Over time, as successive generations of idealized technical innovations are introduced and presented at World's Fairs, in futurists' visions, and in hundreds of billions of dollars' worth of advertising, we develop expectations of a technological utopia here on Earth and in great domed cities in space. We begin to equate technological evolution with evolution itself, as though the two were equally inevitable, and virtually identical. The operating homilies become "Progress is good," "There's no turning back," and "Technology will free humans from disease, strife, and unremitting toil."

Debate on these subjects is inhibited by the fact that views of technology in our society are nearly identical across the political and social spectrum. The Left takes the same view of technology as do corporations, futurists, and the Right. Technology, they all say, is neutral. It has no inherent' politics, no inevitable social or environmental consequences. What matters, according to this view, is who controls technology.

I have attended dozens of conferences in the last ten years on the future of technology. At every one, whether sponsored by government, industry, or environmentalists or other activists, someone will address the assembly with something like this: "There are many problems with technology and we need to acknowledge them, but the problems are not rooted to the technologies themselves. They are caused by the way we have chosen to use them. We can do better. We must do better. Machines don't cause problems, people do." This is always said as if it were an original and profound idea, when actually everyone else is saying exactly the same thing.

As we will see, the idea that technology is neutral is itself not neutral - it directly serves the interests of the people who benefit from our inability to see where the juggernaut is headed.

I only began to glimpse the problem during the 1960s when I saw how excited our society became about the presumed potentials of television. Activists, like everyone else, saw the technology opportunistically, and began to vie with other segments of society for their twenty seconds on the network news. A kind of war developed for access to this powerful new instrument that spoke pictures into the brains of the whole population, but the outcome was predetermined. We should have realized it was a foregone conclusion that TV technology would inevitably be controlled by corporations, the government, and the military. Because of the technology's geographic scale, its cost, the astounding power of its imagery, and its ability to homogenize thought, behavior, and culture, large corporations found television uniquely efficient for ingraining a way of life that served (and still serves) their interests. And in times of national crisis, the government and military find TV a perfect instrument for the centralized control of information and consciousness. Meanwhile, all other contenders for control of the medium have effectively fallen by the wayside.

Now we have the frenzy over computers, which, in theory, can empower individuals and small groups and produce a new information democracy. In fact, as we will see in Chapter 4, the issue of who benefits most from computers was already settled when they were invented. Computers, like television, are far more valuable and helpful to the military, to multinational corporations, to international banking, to governments, and to institutions of surveillance and control - all of whom use this technology on a scale and with a speed that are beyond our imaginings - than they ever will be to you and me.

Computers have made it possible to instantaneously move staggering amounts of capital, information, and equipment throughout the world, giving unprecedented power to the largest institutions on the earth. In fact, computers make these institutions possible. Meanwhile, we use our personal computers to edit our copy and hook into our information networks - and believe that makes us more powerful.

Even environmentalists have contributed to the problem by failing to effectively criticize technical evolution despite its obvious, growing, and inherent bias against nature. I fear that the ultimate direction of technology will become vividly clear to us only after we have popped out of the "information age" - which does have a kind of benevolent ring - and realize what is at stake in the last two big "wilderness intervention" battlegrounds: space and the genetic structures of living creatures. From there, it's on to the "postbiological age" of nanotechnology and robotics, whose advocates don't even pretend to care about the natural world. They think it's silly and out of date.

This first book was intended to raise questions about whether technological society has lived up to its advertising, and also to address some grave concerns about its future direction. Until now we have been impotent in the face of the juggernaut, partly because we are so unpracticed in technological criticism. We don't really know how to assess new or existing technologies. It is apparent that we need a new, more holistic language for examining technology, one that would ignore the advertised claims, best-case visions, and glamorous imagery that inundate us and systematically judge technology from alternative perspectives: social, political, economic, spiritual, ecological, biological, military. Who gains? Who loses? Do the new technologies serve planetary destruction or stability? What are their health effects? Psychological effects? How do they affect our interaction with and appreciation of nature? How do they interlock with existing technologies? What do they make possible that could not exist before? What is being lost? Where is it all going? Do we want that?

In the end, we can see that technological evolution is leading to something new: a worldwide, interlocked, monolithic, technical-political web of unprecedented negative implications.

Jerry Mander, In the Absence of the Sacred, Sierra Club Books, (1992) p2-7

COMMENT: This new series of Blogs is offered for discussion within and between households, in schools and colleges, in local groups of national and international societies, in community and faith centres of all persuasions. The first two were published in 1992, the third in 1945, is followed by three pieces fro 1925. All are concerned with the relentless surge of technological power over the political, economic and spiritual/social spheres of World Society.

Comments welcome.

Medical Progress?

 The last few Blog entries on organ transplants raise fundamental questions: where on earth is medical 'progress', science and new technology taking humanity. Do we really want to go there? Who is calling the tune?

Many of us have witnessed the distress of parents called to a hospital bed after an accident when a young person (under 25 years old) seems unlikely to survive. We can but imagine the further distress at being told that the young person's organs are required for transplantation into somebody else's body. It would seem appropriate to open a public forum on the ethics and desirability, not only of transplants but also of procedures surrounding abortion, contraception, and embryo research. For at least the last decade, many girls who have been prescribed the contraceptive pill to alleviate heavy periods have taken this as a green light to 'safe' sex.

In 1989 Pat Spallone raised the question of ethics in respect of the new reproductive technologies:

"On 25 July 1978, in England, the world's first 'test-tube' baby, Louise Brown, was born to Lesley and John Brown. The birth marked the realisation by a research scientist, Robert Edwards, and his colleague, gynaecologist Patrick Steptoe, that fertilisation of a woman's egg and a man's sperm which took place outside the female body and in a laboratory dish could be placed back into the woman's body and develop to term. The first live birth from 'test tube' fertilisation, or what scientists call in vitro fertilisation or IVF, came after years of experimentation: experimentation which included removing eggs from women's bodies, growing the eggs under laboratory conditions, and eventually entailed inserting the fertilised eggs into women's wombs in the hope that pregnancy would result.

"IVF, the procedure which first entails physiological manipulation of women's bodies to extract eggs, was an invention of the natural science, biology. IVF is one of many biological 'breakthroughs' of the second half of the twentieth century, along with genetic engineering. Biological science, like physics and chemistry before it, has come of age. We are in the midst of a revolution in biology, where control of human reproductive capacities are considered of great importance. In his 1968 book, The Biological Time-Bomb, Gordon Rattray Taylor discussed the IVF research then being conducted, the implications of 'pre-natal adoption' of embryos created by IVF [surrogacy?], sex-choice, artificial wombs, and the future prospect of 'baby factories'. He discussed all these in the context of other scientific breakthroughs, such as organ transplantation, genetic engineering, and the creation of living viruses from non-living molecules. It was a decade before the first 'test-tube' baby was born." (Pat Spallone (1989) Beyond Conception: The New Politics of Reproduction, Macmillan Education p8).

From 1968 these developments have been researched by employees of commercial companies with very little, if any, public debate. As a result, would-be mothers find themselves presented with a range of recommended procedures they never fully comprehend, only to discover, more often than not, that they have unwittingly become research guinea pigs. For many grandparents, the processes in course of development seem indeed, to be 'beyond conception'.

COMMENT: This series of blogs, posted from 10 April 23 (I, Daniel Blake Reviewed) raises issues crying out for further research by specialists and non-specialists alike, for group discussion and practical action at local community level worldwide.

Organ Transplants PART VI and discussion

 

Organ Transplants

Only Fully Informed Consent Valid

If a fair offer of organs is to be made by this means, the wording on Donor Cards must clearly be altered to indicate the true circumstances in which the offer may be taken up. And, given the lack of relevant knowledge and comprehension of these matters which seems to prevail in the general population, it may be that the signatory should be required to acknowledge that he has received a full explanation and understands what is involved.

The same considerations regarding explanation and understanding should, of course, apply when a relative is asked for the organs of a loved-one dying on a ventilator. In this tragic context, real comprehension may be particularly difficult to achieve. However, without it there must remain serious doubt about the validity of the consent sought and given. As things are, it may seem paradoxical that such care is taken to ensure that consent to relatively minor therapeutic surgical procedures is given on a fully- informed basis while consent to the evisceration of a relative is usually sought by staff who are not medically qualified but who - perhaps for this reason and their sympathetic demeanour - achieve a higher percentage of assents to the removal of organs than do the doctors.

It is this great concern that ordinary, public-spirited people have not clearly understood which has been one of the great driving forces behind my efforts to protest during the past decade. Because I feel so strongly that the "harvesting" of hearts etc. is a totally unacceptable abuse of the dying which should not be going on in a civilized society, I have the greatest difficulty in understanding why it is so tolerated. The likely explanation, it seems to me, is that the facts are not well enough known. Some of those who do know and understand - such as nurses and anaesthetists who have been involved - have simply left the transplant scene, usually without public comment. Even some of the surgeons who have been responsible for the removal of the organs have confided to me that they were uneasy about it and did not like doing what they felt they had to do. These pangs of conscience, and their expression, give me real cause for optimism. As one of my advisers commented, some doctors seem to prefer to fudge the scientific issues rather than face the facts about what they're really doing. While that attitude is understandable, it cannot be right or successful in the long term. Sooner or later the truth will out. When it does, I trust that we shall see an end to this misconceived and, to my mind, abhorrent activity — one of the wrong directions taken by Medicine as a consequence of unrestricted technological advances.

Original Editor's Note: Dr. D. W. Evans MD, FRCP retired early from his position of Consultant Cardiologist at Papworth Hospital because of his firm conviction on this matter.

FN :* This refers to so-called "cadaveric" donation. A technique for the removal of a part of a liver from a healthy relative, for transplanting into the recipient, has recently been developed in the U.S.A. While this procedure is not free from ethical problems, they are not of the kind which this paper addresses.

* * * * *

Round Table Discussion

True, the essay on organ transplants was written three decades ago. How has the situation changed, in law? in practice?

How many parents of a young person dying from an accident are presented with the demand to cut out vital organs. Is this a 'good thing' to do?

Note that "Even some of the surgeons who have been responsible for the removal of the organs have confided to me that they were uneasy about it and did not like doing what they felt they had to do". Discuss the moral implications, especially off the last four words.

END

Organ Transplants PARTS IV and V

More Rigorous Test Omitted

It should be noted that steps are taken to prevent the donor from becoming short of oxygen while the ventilator is temporarily disconnected for these test purposes. This is to preserve the donor organs from anoxic damage which would impair their suitability for transplantation. However, this inevitably means that the vital centre in the brain stem which 'controls the breathing - the respiratory centre - is not subjected to the ultimate stimulus (lack of oxygen in the blood reaching it) to see if it can make a last-gasp effort. It is, in fact,tested only for the ability to respond to the less-powerful stimulus of a high carbon dioxide content in the blood still reaching the brain stem.

It should also be noted that the vital centres in the brain stem which control heart-rate and blood pressure are not tested at all under the U.K. protocol. That they are still active in some, if not most, organ donors is shown by the fact that many of them continue to maintain their blood pressure naturally after the declaration of "brain stem death," and by observations of cardiovascular response to the trauma of organ removal which are almost certainly brain stem mediated.

The long and short of it is that these tests are nowhere near adequate to exclude residual life and function in a damaged brain. And, as if that were not bad enough, not even all of these tests have to be done when it is desired to certify death for transplantation purposes. In other countries, there is at least some attempt to test for residual activity in the higher centres of the brain. In the U.K. there is none. If persisting electrical activity (EEG waves) were sought here, it is certain that it could be found in many of these so-called "cadaveric" organ donors. Some would retain function in a part of the brain which controls glandular secretions. These discomforting facts are simply ignored by those who wish to call a donor's brain dead. They dodge the issue of their relevance by not doing the tests which might demonstrate such activity.

The Brief: to Provide Organs in Good Condition

In effect, exhaustive testing for residual life in the brain is proscribed. All in all, the rules governing the diagnosis of "brain death"in this country must be seen for what they are - a simplistic code developed in response to a brief to provide vital organs in good condition for the transplanters. A colleague has likened the process of their formulation to the activities of a committee of foxes taxed with the design of a hen house .....

From the scientific point of view, it is most unfortunate that attempts to diagnose true death of the brain, while some independent bodily functions continued, ever became involved with transplantation. As we have seen, the idea that it might be diagnosable, in some circumstances,was seized upon by those seeking viable human organs, long before it had been adequately thought out or tested. The transplanters simply assumed that what they wanted to believe was true - and have steadfastly refused to consider, or even see, the substantial body of evidence that denies their belief. Had they not become involved, with the consequences that ensued, we might by now be further along the road towards the possibility of secure diagnosis of the true and total death of the brain as an independent phenomenon.

Should that become a scientific reality, the term "brain death" would be an appropriate description. And I, for one, would be prepared to consider the proposition that a patient with a truly dead brain was no longer a human being, i.e. because there is persuasive evidence that the brain is the quintessential organ and the home of the inner self.

PART V

A Better Criterion

However, the final 'cessation of all activity in every part of the brain would be a prerequisite for consideration of this proposition because Man does not yet know very much about the workings of his brain and we cannot, therefore, safely assume that pockets of residual activity here and there do not matter. That being so, we should need clear evidence of the absence of all metabolism, with no possibility of its resuming, in each and every part of the brain. Reliable evidence of the final cessation of blood flow (at normal temperatures) everywhere within the brain would be acceptable for this purpose and it is possible that techniques with the power to demonstrate this reliably (while the body is still alive) may one day become available. At the moment, we can only be sure that the cerebral circulation has ceased for ever when the bodily circulation has finally ceased, i.e. when the patient's heart, or some other pump such as those used in operating theatres to take over the heart's function while it is operated upon, finally stops. This, of course, is the commonly understood criterion of death and the one still used by the majority of the world's doctors to diagnose well over 99% of all deaths.

To sum up, I would urge that:-

(1) The attempt to force upon the professions and public the notion that true death of the brain can be ‘diagnosed reliably, while the body is still alive, be resisted. Likewise the contingent notion that a patient pronounced "'brain dead" on current criteria is truly dead.

(2) It it be argued that the state defined by the "brain stem death" tests is, while not death itself, yet so close to death as to make no practical difference, let the inaccurate and misleading term be abandoned in favour of one which makes the situation clear, i.e. that neither the patient nor his brain stem is really dead at this time, though doomed he may well be. Full understanding of this essential point will perhaps for the first time, enable the opinion-formers of our society to debate the ethics of transplantation in an enlightened frame of mind. Up till now, the highly successful confusion of the dying and dead states, andthe use of weasel-words such as "beating-heart cadavers," has manipulated thought to the exclusion of serious criticism.

(3) The misleadingly-worded Donor Cards be withdrawn immediately.

Many selfless prospective offers may have been made on a basis of serious misunderstanding; the signatories may have thought that the words "after my death" on those cards meant after their deaths in the commonly-understood sense of the term. Indeed, I know that some highly-intelligent and otherwise well-informed people have carried these cards thinking that they were thereby authorising removal of their organs after the final disconnection of the ventilator and the subsequent final cessation of their circulation. When disabused of this cosy notion, some have expressed horror and some disbelief. Most, when the truth has dawned, have destroyed their cards; a few have continued to carry them after modification, e.g. specification that a general anaesthetic be administered during removal of the organs.

To be continued ...

Organ Transplants Parts II and III

PART II

The Dying are not yet Dead

However, even if the tests could infallibly forecast death in the commonly-understood sense of the term within a few hours or days, would it be right (or logical) to hold that the patient satisfying these criteria is - to all intents and purposes maybe - already dead? I maintain that it is not correct, or proper, to confuse this state in which he is doomed to die soon - however certain that may be - with death itself. To my mind, a comatose patient without brain stem reflexes and dependent upon a mechanical ventilator is still a living human being; as such he is deserving of our every care, without intrusion of any third party interest, right up to the time when his circulation finally ceases and he can be truthfully described as a cadaver.

I continue to maintain this view despite its being dismissed, by the transplanters, as reactionary and akin to the stance of members of the Flat Earth Society The implication is, I suppose, that it is somehow improper to examine too closely the fundamental concept and science involved in this novel re-definition of death because it has made possible such wonderful surgical advances. In other words, the spectacular achievements are held to justify the means - which (they appear to suggest) are therefore best left decently veiled. I think that a very dangerous philosophy. And having said so, I also have to say that I am far from convinced that transplantation of these vital organs really does constitute a lasting therapeutic advance. There is, in fact, no scientific evidence that - taking all relevant factors into account - these transplant procedures do more good than harm. As a perceptive colleague remarked, cardiac transplantation probably increases rather than decreases the sum of human misery. But the over-statement of the benefits, the impossibility of knowing the natural prognosis, and the many other clinical and logistic difficulties are - like the prospects for alternative ethical treatment strategies - another part of the story.

Correcting a Misleadingly Rosy Impression

Had the public been fully and frankly informed on all the relevant aspects, it might not have been persuaded that it wants transplantation at almost any cost. That it has been so persuaded - as I am frequently assured it has - offers ample testimony to the power of the media in forming public opinion. My hope is that the many sincere and highly talented people involved in journalism and broadcasting will, now that they are beginning to understand the facts of the matter, wish to use that same power to correct the misleadingly rosy impression of this really rather macabre activity which they may hitherto have helped to propagate. But their task will be far from easy, given that Society seems now to demand of Medicine that it shall provide an answer to Man's mortality.

To return to the fundamental issue, I must record my surprise and disappointment that theologians, philosophers and lawyers appear to have accepted the propriety of certifying and treating as dead, a patient on a ventilator who - though almost certainly doomed to die soon - still has his own natural blood circulation and other bodily and brain functions at the time. Some of them, apparently, see no essential difference between this late stage in the dying process and death itself; once the tests have pointed to a fatal outcome, he is "as good as dead," they say, and can be dealt with accordingly - though few, I imagine, would bury or cremate a man with a beating heart.....

Others, including members of the judiciary I'm told, do understand the factual difference between the dying state called "brain stem death" and true death but do not think it matters in practice. The useful life of the patient on the ventilator is clearly over, they say, so why should his organs not be removed while there is still life in him if this is necessary for them to be of use to others? The fact that the donor has to be certified "dead " - by some doctors using arbitrary criteria which many or most doctors would not deem sufficient for the purpose - has to be accepted as a necessary preliminary to the surgery (to avoid the obvious legal and ethical difficulties). The rights and wrongs of such certification are, they say, beyond their understanding and a matter for "the medical profession."

There is, in the U.K., no legal definition of death and so, where the Law is concerned, a person is dead when a doctor certifies him "dead." By this means, the legal profession sidesteps the fundamental issue. But what would happen, I wonder, if one or more doctors certified a person dead and others (like me and many more) were willing to testify that he was still a living human being, and certainly not a corpse, when he was being operated upon for the removal of his vital organs? Or if the precise time and date of death mattered very much in the settlement of a civil action and one doctor said the deceased was dead at the time when the " brain stem death" criteria were sought and satisfied while another said he was not dead at that time and did not actually die until his heart was removed some hours or days later?

PART III

Where might it Lead ?

Such legal niceties apart, it seems to me that it is important not to allow confusion of "dying" with "dead" simply to avoid facing up to the ethical problems, e.g. allegations of active euthanasia, which beset even today's secular, utilitarian society. The "slippery slope" argument seems to me to have some force in this context. If utterly helpless young people being kept alive by mechanical ventilators today, whom will it be deemed appropriate to use as sources of organs and for experimental purposes tomorrow? Newborn babies with little or no forebrain (anencephalics) but who cannot, by any stretch of the imagination, be regarded as "brain stem dead " have already been used thus ....

It occurs to me that those theologians and others who have accepted the notion that "brain stem death = death" may have been misled, for this is the stated basis for the move, in 1979, by those satisfied there is no function remaining anywhere in the brain and no possibility of any such function ever returning, whatever may subsequently be done. It would not be surprising if they had been so misled for this is the stated basis for the move, in 1979, by the Conference of the Medical Royal Colleges of the U.K. from use of the"brain stem death" criteria as a justification for turning off the mechanical ventilator (so that natural death might be allowed to occur) to their use as a basis for the certification of death itself. This change of use was clearly prompted by the perceived need to provide hearts and livers in a state suitable for transplantation; it served no other purpose, there being no need to certify death before discontinuing life-support solely in the interests of the patient (and his near and dear).

It was to provide a consensus basis for that most onerous decision,i.e. to terminate what was clearly otiose and unkind therapy, that so-called "brain stem death" criteria were promulgated by the Conference in 1976. The criteria were a distillation of those we had been using informally for some years and in which we had developed confidence with regard to their ability to forecast death within a short time of their fulfilment. I did not object to their propagation for that stated purpose for it seemed to me that their general adoption would make such decisions more comfortable, particularly for those faced with the problem only occasionally. However, in retrospect, I should perhaps have been suspicious that the stated purpose (in 1976) was not the only purpose even then envisaged because the Memorandum publishing the criteria acknowledged the involvement of the Transplant Advisory Panel .....

Policy Confuses Prognosis and Diagnosis

Be that as it may, Conference - the policy-making body to which the D.H.S.S. appeals for advice - simply decided, in 1979, that the sesame criteria which we had been using for purely prognostic purposes should henceforth be used, without modification, for the diagnosis (and certification) of death itself, i.e. while the 'circulation and other vital functions continued naturally. The justification offered for this enormous leap was that by the time these criteria were satisfied "all functions of the brain have permanently and irreversibly ceased." The redundant terms are interesting, and may betray lack of confidence in their momentous edict. To almost anyone of a truly scientific disposition, and particularly to those with experience of the biological sciences, such a claim must have seemed at the very least incautious and - given that the criteria do not require that the greater part of the brain be tested at all - perhaps frankly ludicrous. But to understand the full absurdity of this claim, some knowledge of the tests used to diagnose "brain death" is necessary and I will therefore attempt to outline those in use for the purpose in this country.

It is, of course, a requirement that the patient be deeply comatose (though grades of unconsciousness are, in point of fact, quite difficult to determine) and unable to breathe spontaneously, i.e. air is being delivered to his lungs by a mechanical ventilator. It is worth mentioning that this is the only function of this so-called "life-support machine"; it does not take over the circulatory function, as a lot of people seem to think. The blood flow through the body and parts of the brain, in such a patient, is maintained naturally by the beating heart.

It is a requirement that the cause of coma and ventilator dependence be known; common causes are severe head injury and bleeding into the brain but in some cases the brain damage is due to a period of anoxia and its extent may then be less easy to determine. When,after a few hours or several days, it seems likely that a (fatal outcome will inevitably ensue, some of the reflexes with pathways through the brain stem - the stalk that connects the major part of the brain (the cerebral hemispheres) to the spinal cord - re tested. This involves looking for eye responses to light and to touch, and to the indirect stimulation provided by irrigating the ears with ice-cold saline. There?must be no movements in the head and neck area in response to stimulation of any part of the body. Nor must there be any response to stimulation of the throat or windpipe. Finally, to test the all important supposition that the patient will never again be able to breathe on his own, the mechanical ventilator is disconnected for 10 minutes; if there is any sign of a spontaneous inspiratory effort during this time, then the criteria for "brain stem death" are not satisfied. If there is no sign of any attempt to breathe, mechanical ventilation is resumed and an unspecified period of time is allowed to elapse before the brain stem reflexes are again sought. If they remain absent the ventilator is again disconnected for a similar test period. If there is still no inspiratory effort, and if temporary influences such as drugs have been excluded, the criteria for the diagnosis of "brain death" - U.K. style - have been satisfied and the patient is certified dead.

Mechanical ventilation is continued thereafter, sometimes for days, while the complicated arrangements are made for removal of his vital organs and, of course, throughout the surgical procedure involved in acquiring them.

To be continued ...