Finished with that kidney?

A new book asks tough questions about organ harvesting and the definition of death

The Undead: Organ Harvesting, the Ice-Water Test, Beating-Heart Cadavers — How Medicine Is Blurring the Line Between Life and Death

by Dick Teresi

Pantheon, $26.96, 368 pp.

In his new book The Undead, science writer Dick Teresi paints a macabre picture of a booming organ-donation industry in which doctors and hospitals may be more concerned with getting a "healthy" organ into a dying patient than with ensuring that the organ donor is indeed dead. And in doing so, Teresi takes what may seem a no-brainer to many of us — donating our organs to those in need when we no longer need them ourselves — and turns it into something that could be, in a very real sense, painful and terrifying.

The Undead fits into that branch of science journalism that dips its toes equally into the pools of research, history and the metaphysical. Teresi explores the history of death, from ancient Egypt to the anatomy theaters of the Renaissance. (Unfairly, he spends not even four full pages of the nearly 40-page chapter "A History of Death" on "non-Western traditions.") Even in the era of cardiopulmonary death — death of the heart and its supporting systems — declaration of death was not simple. Some morgues would keep bells tied to the toes of the dead in case they should wake up before burial; tests such as holding a mirror under the nose to check for breath were common. But as medical technology improved, the nascent concept of brain death complicated matters: Suddenly, there was the possibility that inside a seemingly inert body, a conscious being could lie.

Thus, in the Aug. 5, 1968 edition of the Journal of the American Medical Association, 13 scientists and academics who had gathered at Harvard Medical School to discuss brain death published an article titled "A Definition of Irreversible Coma." In three-and-a-half pages, the article laid out criteria for determining that a patient had a permanently nonfunctional brain, thereby rendering him dead. This eventually led to the 1981 Uniform Definition of Death Act, which still stands today, and which states that "... the entire brain must cease to function, irreversibly. ... This act is silent on acceptable diagnostic tests and medical procedures." As Teresi puts it, the UDDA "ends by stating that doctors who declare death cannot be prosecuted criminally or 'liable for damages in any civil action' as long as they act in 'good faith.'"

The operating table now prepared, Teresi gets to the juicy stuff: examining what the act means for us physically, economically and philosophically. He takes on the subject from every front imaginable: He introduces a woman who claims to have been awake for months while being treated like a vegetable; he visualizes the inconsistencies in brain-death laws by describing a road trip in which a body, transported from coast to coast, could technically die and return to life over and over as it crossed state lines; he delves into the mystical world of near-death experiences. All of it proves that what we think of as a simple question — dead or alive? — is anything but.

Understandably, the book has not been well-received by organ donation recipients and their loved ones. But Teresi cites statistics and quotes specialists so frequently that it is hard to ignore him, despite his sometimes heavy-handed tone. The transplant industry is a $20 billion-a-year business, with more than a billion dollars of that sum spent on immunosuppressive drugs, which organ recipients require for the rest of their lives. Transplant surgeons average salaries around $400,000, and hospitals often receive "finder's fees" — by law, the only participants who can't profit from an organ donation are the donor's family.

Teresi's conversations with anesthesiologists who feel uncomfortable during organ procurement procedures are among the most engaging. Anesthesiologists, in the words of one, are there to act as a patient's advocate while he or she is unconscious during a surgery. They monitor vitals, and ensure that the patient remains pain-free as the surgeon concentrates on the procedure. Patients' blood pressures often spike during surgery, which can be an indication of pain; in most — if not all — cases, administering more anesthetic brings the blood pressure levels down. During organ procurements, blood pressure levels can spike, but anesthesiologists aren't allowed to do anything about it, because, as Teresi paraphrases Mark Schlesinger, chairman of the department of anesthesiology at Hackensack University Medical Center in New Jersey: "1) transplant surgeons don't want to risk the organs, and, more important 2) they don't want to know; finding that donors were in pain while their organs were being removed during a multi-hour operation would not be good for business." Or, as Daniel Teres, the 23-year chief of critical care at Baystate Medical Center puts it, "If you wait for everything to be 100 percent, you'd never have organ donation."

The Undead is not a comforting read, but it is a fascinating one. Boasting the same allure as popular TV shows like House and Mystery Diagnosis, it is likely to leave you with a new angle on human consciousness. Consider, as Teresi asks you to, what might happen if a caterpillar were to commit a crime, only to be arrested after it had become a butterfly. "These may seem like facetious questions," Teresi writes, "and in part they are. But it strikes at our new definitions of death, which rely more on philosophy — when does the 'self' leave the body? — than biology. ... No biologist claims that the caterpillar dies and a moth is born. It's the same animal. Yet most of the caterpillar's cells have died, irreversibly, particularly in the brain, far more than have died in human patients declared brain-dead."

Laura Dattaro is the former associate editor of Baltimore's City Paper, where this piece originally appeared. Send comments to [email protected]. 

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