purpose statement

This blog records the experience of a Catholic medical student.

Saturday, August 30, 2014

Organ Donation: Is Your Soul Gone when Your Brain Dies?

I had some experience while on my trauma/acute care rotation with brain death and organ harvesting. One of my good friends was on the transplant service at the same time. "I think there's a harvest tonight," I said to him one day. A patient on our service, who had come in with severe brain damage after a hallucinogen-associated accident, had been declared brain dead. His family had consented to donation. I saw the organ donation representative with his binder and papers hovering around the room. And the patient's name disappeared from our check-out list (the list we keep of the patients so that we can hand them off to the night team). Sure enough, there was a harvest that night.

It sounds macabre, and it is. Late one evening, I was walking down the long hall of operating rooms to get a snack out of the physician's lounge. I passed by the screen at the front of the OR that displays all ongoing surgeries. Each operating room has a row, and the cases stretch out like long ribbons along the row, with every hour taking about three inches on the screen. Because it was 7:00 or 8:00 in the evening, no elective cases were scheduled. There was a laparoscopic appendectomy posted for the near future: it was about eighteen inches long on the screen. But at the bottom of the screen stretched an enormous band of orange, disappearing to either end of the screen. "HARVEST" was the procedure.

I walked down the hall. Outside the room's door were many styrofoam crates with plastic bags labeled "human organ for transplant" and advisories about temperature and transport. There was a liver box, a kidney box, a heart box, a box for blood.... No shades were drawn over the windows, so I looked in. The body on the table looked pale; I later realized that this was because blood was being taken. And instead of a cot or hospital bed waiting outside the door, as in every surgery, there was a long box on wheels. A tank, from the morgue.

The Catechism, in 2296 (in the section on Respect for the Person in Scientific Research) has this to say about organ donation:
Organ transplants are in conformity with the moral law if the physical and psychological dangers and risks to the donor are proportionate to the good sought for the recipient. Organ donation after death is a noble and meritorious act and is to be encouraged as a expression of generous solidarity. It is not morally acceptable if the donor or his proxy has not given explicit consent. Moreover, it is not morally admissible to bring about the disabling mutilation or death of a human being, even in order to delay the death of other persons.
I had heard the horror stories about people (rather than bodies) being harvested. But med school gave us training to recognize legitimate brain death. This included forceful reminders that that two physicians must agree on the criteria. But is brain death a suitable way to determine that the soul is gone?

Maureen Condic, Ph.D. wrote a helpful essay entitled "Life: Defining the Beginning by the End." Published in 2003 by First Things, the essay discusses the beginning of life by considering death. I was already a Condic fan, because of her phenomenal (and unsung) white paper on the beginning of life, and because I was a Vita Institute participant.

Condic highlights the distinction between cellular (or even organ) life and life of the organism. (Busy people read the bold.)
Brain death occurs when there has been irreversible damage to the brain, resulting in a complete and permanent failure of brain function. Following the death of the brain, the person stops...sensing, moving, breathing...although many of the cells in the brain remain “alive” following loss of brain function. The heart can continue to beat spontaneously for some time following death of the brain (even hearts that have been entirely removed from the body will continue to beat for a surprisingly long period), but eventually the heart ceases to function due to loss of oxygen....

The fact that the cells and organs of the body can be maintained after the death of the individual is a disturbing concept. The feeling that corpses are being kept artificially “alive” as medical zombies for the convenient culture of transplantable organs can be quite discomforting, especially when the body in question is that of a loved one. Nonetheless, it is important to realize that this state of affairs is essentially no different from what occurs naturally following death by any means. On a cellular and molecular level, nothing changes in the instant of death. Immediately following death, most of the cells in the body are still alive, and for a time at least, they continue to function normally. Maintaining heartbeat and artificial respiration simply extends this period of time. Once the “plug is pulled,” and the corpse is left to its own devices, the cells and organs of the body undergo the same slow death by oxygen deprivation they would have experienced had medical science not intervened.

What has been lost at death is not merely the activity of the brain or the heart, but more importantly the ability of the body’s parts (organs and cells) to function together as an integrated whole. Failure of a critical organ results in the breakdown of the body’s overall coordinated activity, despite the continued normal function (or “life”) of other organs. Although cells of the brain are still alive following brain death, they cease to work together in a coordinated manner to function as a brain should. Because the brain is not directing the [diaphragm] to contract, the heart is deprived of oxygen and stops beating. Subsequently, all of the organs that are dependent on the heart for blood flow cease to function as well. The order of events can vary considerably (the heart can cease to function, resulting in death of the brain, for example), but the net effect is the same. Death occurs when the body ceases to act in a coordinated manner to support the continued healthy function of all bodily organs. Cellular life may continue for some time following the loss of integrated bodily function, but once the ability to act in a coordinated manner has been lost, “life” cannot be restored to a corpse”no matter how “alive” the cells composing the body may yet be.
If that sounded interesting to you, I encourage you to read the rest. Condic goes on to talk about how this definition excludes persistent vegetative state (i.e. we can't argue that Terry Schiavo should die from agreeing that brain death = death), and that this definition does not hang on consciousness or cognitive function (i.e. we can't euthanize the unborn, the disabled, or the demented because we agreed that brain death = death). I disagree with a few of Condic's assertions, notably that we cease to think upon brain death. (who, with the light of faith on matters like the communion of saints, would say that the soul, separated, cannot think without the brain?) But the rest of her work is medically excellent as far as I, eight months from M.D., can see. This is also philosophically sound as far as I, a bachelor in philosophy, can see.

When I initally got my driver's license, I was still undecided about organ donation. I renewed it recently, and I'm now a donor. I encourage you to prayerfully consider donation, too. Besides saving up to 8 lives, you could also bring closure to your family after your death, all in accord with Catholic teaching, sound philosophy, and accurate medicine.

(Spoiler alert: that's not my license at left.)

Thursday, August 7, 2014

Mini Post: Living downtown is awesome

I haven't been able to sit down and blog for so long! I have a bunch of ideas for posts all piled up on my phone's "To Do" list, but so little time to sit and execute them. I'm on a subspecialty away right now and (aside from the fact that I missed an emergency surgery last night), I'm doing what I need to do with pretty liberal free time.

Therefore, we will now have a moment to spit out all the blog post ideas in miniature.

I've moved several times since I started med school. Suburb 1 (my first location) was very quiet. The only remarkable thing I ever experienced among my neighbors or in my apartment complex was the messy morning relationship fight I accidentally witnessed across the street while on my balcony one morning for breakfast. (It was a lot like the movies: the guy slams out the door with a suitcase, the girl comes out after him very distressed, pleading loudly....) Suburb 2 was even quieter. Now I live downtown in one of the country's largest cities. And I'm living with a different population, since I'm living in a lower socioeconomic area. I see homeless people daily, I see broke people daily, I see mentally ill people frequently, I see people with much narrower prospects than mine all around me.

But I love it. I feel like I'm appropriately living the way an alter ecclesia should live: poor and with the poor.

And sometimes it's pretty funny. While biking home one day, I stopped at a light and smiled at the man sitting at the nearby bus stop. "Wher' yo' husband at?" he asked, without any other greeting.

"I'm married to Jesus," I answered.

"Oh," he replied, not knowing what else to say. "That's coo'."

"I thought so," I answered. The light turned green and I moved on. That was already the second time someone had asked me where my husband was.

Another time, I was finishing a conversation with a homeless man after Mass at the cathedral. I introduced myself and he said, "All ri', mmatins, my holla' sista."

I love to be with the people in my neighborhood. Just being in the same place, shopping at the same stores, using the same laundry machines, putting up with the same pigeons, and walking the same streets is teaching me about how hard these people work and how much love we all need. It's humbling and exciting. (That may or may not be where I'm living; I didn't even check before I used the picture; thanks to Kim Briggs)

Thursday, July 24, 2014

Should Catholic Parents give their Children Gardasil?

Gardasil (and its sister vaccine, Cervarix) received lots of press seven or eight years ago, but I'm retouching the subject because I am getting Gardasil. (I'll explain why later.)

Basic Science (skip if you don't care or already know this)
Gardasil is approved by the Food & Drug Administration (FDA) for prevention of human papillomavirus (HPV) infection in people aged nine to twenty-six. (Gardasil for male and female patients, Cervarix currently for females only.) Like many vaccines for other viruses (e.g. the yearly "flu" vaccine), it innoculates the body with a recombinant protein pulled from the virus, so that the immune system learns to defend the body against that virus in the future. Gardasil is "quadrivalent" and protects against HPV types 16 and 18 (the types most associated with cervical cancer) and types 6 and 11 (the two most common types seen in genital warts). Cervarix is bivalent, offering immunization against types 16 and 18 only.

Morality (don't skip this)
HPV is a sexually-transmitted infection. Cervical cancer is a sexually-associated cancer. This makes Gardasil and Cervarix unlike every other vaccine that a Catholic parent may choose to give their children. Several moral questions arise:
  1. Is it moral to administer this kind of vaccine?
  2. Is it prudent?
  3. Is it imprudent not to receive this vaccine?
  4. Is there ever a case that a person should receive this vaccine?
(The derivation of culture cells from aborted children is beyond the scope of this post, as is herd theory and preference against vaccination. For the remainder, I assume that the parents reading accept the premise behind vaccination in general.)

Is it Moral to Administer HPV Vaccines?
The Catholic Medical Association (CMA) has a position paper on HPV vaccination which I find full of sound medical practice, reason, faith, duty to do what is right, and a spirit of obedience. They answer this question in this fashion:
The fact that HPV is spread primarily by sexual contact does not render vaccination against it unethical. Healing and preventing diseases, no matter what their source, are acts of mercy and a moral good. Prevention of HPV infection is distinct from, and should not be construed as encouraging, the behavior by which HPV is spread.
Per se, HPV vaccination is not an immoral act.

But is it Prudent?
Will we change promiscuity? time will have to tell. It remains true, as CMA points out, that
...to best promote the health and happiness of adolescents, physicians, parents and social institutions should redouble their efforts to promote chastity. Consistent messages about and support for this virtue will not only help to reduce disease, but will help individuals, couples, and marriages to flourish. 
So is it Imprudent Not to Get these Vaccines?
Not really. CMA points out that the HPV vaccine is not the only way to prevent cervical cancer. In fact, cervical cancer is the poster-child cancer for prevention by cheap, easy screening (the Pap smear), which has not been connected with increased promiscuity

CMA also adds that the vaccine's long-term effectiveness isn't proven, and that there are eleven other subtypes of HPV that have been associated with cervical cancer. (These facts are part of the ordinary informed consent that physicians should provide to patients. By and large, I have not seen that OB/GYNs are great about giving all of this information before giving Gardasil and Cervarix. The good ones point out that the patient can still get other types of HPV.)

Is there Ever a Case that Should Receive this Vaccine?
I was spurred to write this post when I chose to "get Gardasil" (as an adult, at the tail end of the FDA's recommendation). Why? Because an attending told me that a colleague in the metroplex had respiratory papillomatosis from inhaling smoke from surgical cautery. In other words: after operating on infected cervixes day after day, an OB/GYN got the equivalent of genital warts in his windpipes! (Not fun.) Not the only case reported, either: a 2005 review cited "A case report [linking] the laryngeal papillomatosis in [a] ... surgeon to virus particles in the laser plume from one of his patients."

Some parents have told me they choose to vaccinate their children considering that you will never know who masturbates without washing their hands before touching your children (a stretch, but parents stretch all kinds of things for their children, and I can't argue--no one loves your children as much as you do). A young man or woman who finds that their intended has had previous sexual encounters may have reason to seek vaccination (I have seen a case of cervical cancer in a monogamous woman from her husband, who was faithful to her after marriage, but had had a previous partner).

In short
HPV vaccines aren't per se illicit. It may contribute to an increase in promiscuity; physicians don't always give water-tight informed consent about things they think are good, patients don't always understand informed consent, and advertising muddies the picture. Time will tell whether people mistakenly take the HPV vaccines to be a ticket to consequence-free sexual license. Ought parents to vaccinate? I can't make the case for all, but I respect each parent who chooses, in love, to vaccinate their children or to allow their children to choose vaccination. Are there cases when people really should? I thought so.

This is respiratory papillomatosis. The whitish globular growths are papillomas,
in the normally V-shaped valley of the larynx. Source: viveromd

In writing this post, I used the full prescribing information for Gardasil and Cervarix.

P.S. At the time the CMA position paper was written, there was much debate about whether HPV vaccines should be mandatory. That's a moot issue now, but I love CMA's answer. The paper points out brilliantly that since non-vaccinated students would not present an increased risk to vaccinated students while in school, as with droplet-communicable infectious diseases (e.g. measles). I have to quote it:
We presume that genital HPV infection is not transmitted while students are in school, and excluding non-vaccinated students from school would not prevent extramural transmission.
Come on, you have to smile. "We presume that schoolchildren are not having sex in the classroom." ROFL.