Having decided that the general principle of organ donation is not necessarily wrong, we now need to know under what circumstances it is permissible. First, we will touch on differences between various organs. Then, we will focus on different types of donors. Significant attention will be given to the definition of death, as this is pivotal to most major organ transplants.

1. Based on Type of Organ⤒🔗

First, consider the various types of organs that have been transplanted, including heart, lung, liver, pancreas, kidney, heart valves, corneas, bone marrow, bone, skin, blood products, and some brain cells. Bowel transplants have been attempted, but I don't think there have been any successes. Setting aside how the organ is retrieved from the donor, is there anything inherent in any of these organs that sets its transplantation apart as right or wrong?

Does the Bible give any organs special status in a physical sense? Apart from the symbolic value that different organs have, I don't think there is any passage that places a special physical importance on one organ over another. The heart portrays a very unique symbol because physically the heart is the driving force behind the movement of the blood or the life of the body.

Corneas may be distinguished from all other organs because they are bloodless. This may give them special status, if the issue of transplanting organs with the life blood is considered to be important. The group of organs that are essential for life have a physical impor­tance. These organs include the heart, liver, pancreas and brain cells. If any of these are removed, the person they are removed from cannot survive. This is a problem if they are taken from a living person, as this would vio­late the sixth commandment.

All organs are useful to transplant only if their cells remain viable. By viable, I mean that the cells of the organ are able to continue to perform their function. This means that the cells must be alive. Once a cell in our body dies, it cannot be brought back to life by natural means. For the function of the dead cell to continue, it must be replaced by a new, living cell. This means that every successfully transplanted organ has living cells in it at the time it is transplanted. Once the lifeblood (Gen. 9:4) is cut off, organs die at different rates. The rate cells die depends mainly on the cell's energy require­ments and the ability of the cell to turn its metabolic rate down to save itself. All cells can be slowed down by cooling.

The organ most sensitive to the loss of blood circulation is the brain. Its cells begin dying within four minutes of circulation failure. Next, are the liver and pancreas. The kidneys and heart can survive a short time without blood supply, although they are likely to be scarred and not function as well. Skin and muscle can survive a few hours and corneas can survive several hours.

The less time it takes for damage to occur, the more likely will the organ be useful for transplanting. This leads into our consideration of the different types of donors.

2. Based on the Type of Donor←⤒🔗

Based on the circumstances of organ retrieval, some clear distinctions exist between various organ transplants. How the organs are obtained is the most controversial issue surrounding transplantation. For example, a kidney donation from a willing, living donor, such as the recipient's brother, may be right. Whereas, most would agree it is wrong to use a kidney from a criminal whose life was sacrificed in order to obtain organs. According to news reports, this happens in China.

As we consider how organs are obtained, we will review various donor types, including clearly dead or cadaver donors, questionably dead donors, living donors, use of fetal parts (from aborted babies), and animal donors. Notice that the different types of donors are distinguished by their relationship to death. Therefore, we need to consider the definition of death.

Generally, we can be certain death has occurred if there is an irreversible loss of breathing, circulation, and all signs of brain activity. These donors I will classify as clearly dead.

The heart, lungs and brain seem to be the major organs governing the principal signs of life. They are the sources of circulation, breathing, and direction. Any of these may stop functioning for a period of time and later be restored. Circulation and breathing, indeed, can be maintained by artificial means.¹

Resuscitation and life support, utilized when a person's breathing or heart has stopped, evokes questions about traditional definitions of death. A study of death in the Bible does not seem to help us to define death. John Frame, in his book, Medical Ethics says,

Scripture does not formally define physical death but assumes that we understand what it is. Clearly, however, Scripture does recognize a point at which efforts to save a person's life, even by prayer, are to be abandoned (2 Sam. 12:19-23). If there is any criterion of death noted in the scripture accounts, it would be cessation of breathing, though Scripture does not present this as a technical criterion but simply a matter of empirical observation (Josh. 11:11; 1 Kings 15:29; 17:17; Job 27:3; Ps.104:29; Isa. 2:22; Gen. 2:7; 6:17; 7:15, 22; Ezek. 37:5; Acts 17:25).²

With respect to breathing, circulation, and brain activity he says,

The heart, lungs and brain are mutually dependent. The brain requires oxygen and blood; lung operation requires blood and brain-direction; heartbeat requires oxygen from the lungs, which in turn are dependent on brain function. Therefore, when one function is lost for a long enough period of time, the others will be lost as well. But, again, complications arise when functions otherwise lacking are maintained artificially. One cannot really tell if a patient has lost lung function unless the patient is removed from life support.

This ambiguity encourages using death of the brain to define death of the person. As we will see, donors pronounced "brain dead" while the body is still living are desired by proponents of organ transplants. I will classify these as questionably dead donors.

a. Clearly Dead Donors←↰⤒🔗

Having described what is meant by clearly dead and by questionably dead donors we can now look at each special type of organ donor. First, the clearly dead or cadaver donors are those where there is no question that death has occurred, since all signs of circulation, breathing, and brain function are absent for a long enough time. The only human parts that remain useful in this situation are skin, bone, and heart valves and corneas from the eyes.

Skin and bone can usually be obtained from the patient or from a living donor. Pig and synthetic heart valves are so successful that human heart valves are not used. In practice, corneas are the only human parts used from clearly dead donors. As long as the eyes are removed within eight hours of death, the corneas can be used. Since the process of decay of the body has begun in a clearly dead person, meaning, as we will see later, that the soul has departed from the body, it is not a violation of the person to take the corneas.

b. Questionably Dead Donors←↰⤒🔗

All major organs such as, heart, lungs, liver, kidneys, are very sensitive to loss of blood circulation. These organs cannot be successfully transplanted from clearly dead donors because to be successful the organs need to be alive. In a clearly dead person, the heart has stopped. The blood flow stops when the heart stops and the blood begins to separate. Blood cells clump together into clots. This process is described in the Bible when the soldiers pierced Christ's side and water and blood came out, indicating that Jesus was really dead.

Once the blood clots, it becomes impossible to clear these clots out of an organ's very small blood vessels. If such an organ were to be transplanted, a lot of its blood vessels would be blocked and not be available to the recipient's circulatory system. To overcome this problem, the blood must be replaced with preserving fluid at the time of removal.

Also, the cells of these organs are very dependent on a steady supply of oxygen and other nutrients. Once the blood flow stops, cell damage and cell death quickly fol­low. Cells of the non-cooled brain are irreversibly damaged within four minutes of no blood flow. It does not take much longer for other major organs to be damaged beyond repair. To overcome this problem special cooled replacement fluids are put into the organ while the donor's blood is still flowing or almost immediately after the blood has stopped flowing.

Therefore, most major organs are taken from a donor with a beating heart. In practice, a donor is declared brain dead in an intensive care unit, often after some form of trauma such as a car accident. Those who are in intensive care units due to disease, rather than trauma, are usually not suitable as donors because of the disease process. Once declared brain dead, the heart continues to beat on its own and breathing is maintained by a machine. While on the machine, the donor is taken to the operating room. Breathing and circulation are maintained while the organs are dissected from the body. The last thing disconnected from the organ is the blood supply. At the same time, the blood in the organ is replaced by a cooled preservative fluid. Then, there is a rush to get the organ into the recipient so that the recipient's blood can provide what is needed to keep the organ alive. This needs to occur within hours. The longer it takes, the less likely the organ will survive.

If the use of live body parts is considered appropriate, the main ethical issue with the donation of these major organs is with the declaration of death. Unless we resort to taking organs before death is declared, we need to be able to declare death while the heart continues to beat for these transplants to succeed. Declaring "brain death" while the body is still alive meets this need.

Brain Death←⤒🔗

"Brain death" is a relatively new term. An ad hoc committee of the Harvard Medical School first proposed brain death criteria in 1968.³  This committee described criteria to define irreversible loss of function of the whole brain. Using these criteria, survival of the brain is very unlikely, but as we will see, death of the brain does not necessarily mean the death of the person. Only when the brain is effectively cut off from the other two determinants of life, breathing and circulation, can we be sure death has occurred when the body is still alive. There are only a few mechanisms that will lead to this situation.

The most definite one is a severe head injury that leaves the body relatively intact. In such a case the brain swells and the pressure inside the skull closes the veins. The arteries continue to deliver more blood, dramatically increasing the pressure, until the arteries close as well. This effectively cuts off the brain's blood supply. In a short time the cells of the entire brain can die. In such a case, an angiogram will show that there is no blood flow in the brain.

A severe stroke is another situation that may result in brain death. If the stroke causes enough brain swelling, it can result in the same situation as in severe head injury. It is important to realize that most strokes do not cause enough swelling to entirely stop the blood flow to the brain. Therefore, only part of the brain dies.

The final situation that may result in brain death, while sparing the body, results from CPR (cardiopulmonary resuscitation). The idea of CPR is to supply some blood flow to the brain, when the heart has suddenly stopped, until the heart starts beating again. If CPR is started within a few minutes and the heartbeat is restored within about eight minutes, the brain may be spared. If it takes longer, the cells of the brain will begin to die. Because the organs of the body are less sensitive to lack of oxygen than the brain, it is possible that the brain could die and the body remain alive. This happens only in exceptional cases. Most often, if the brain doesn't survive, the organs of the body will be damaged too. If the body does survive, at least part of the brain likely survives too.

Use of the Term "Brain Death"←⤒🔗

We have seen that it is possible for the brain to die and the body to remain alive. In medical terminology the term "brain death" is used to mean more than just the death of the brain. It is used to mean death of the person when the body is still alive. I want to explain why "brain death" has come to be used this way.

It is widely recognized that the main motivation for the development of this definition of death is the desire to obtain organs for transplant, as Dr John Doyle, of the University of Toronto, in a paper supporting the diagnosis of brain death, admits.⁴ Also, there is an interesting connection between the development of drugs, like cyclosporin, that prevent rejection of a transplanted organ, and the movement toward acceptance of "brain death."

It has also been suggested that the expense and emotional trauma of maintaining people on life support are the motivations for the development of brain death criteria. However, it is not likely that strict brain death criteria will solve this perceived problem of "keeping someone alive" in an intensive care unit. Many unconscious patients in intensive care units will not fit strict whole brain death criteria. Also, the problem of keeping some­one alive on life support can be addressed without brain death criteria, as it is not always inappropriate to disconnect life support and leave the life of a person in God's hands.

Furthermore, consider who is promoting this significant change in the definition of death. It is the scientific community; primarily those interested in transplants. Christians have tended to place significant trust in the medical community, which has until recent years, at least paid lip service to a morality that considered God's standard. We are quickly losing this heritage. Consider Psalm One that says, "blessed is the man who walks not in the counsel of the ungodly."⁵ We must be careful not to naively accept the counsel of the ungodly. Their counsel must be tried by the Word of God by which we must "test all things and hold fast to what is good."⁶

Proponents of organ donation claim that the opportunity to save lives is being lost. They claim that we are only harvesting a small number of the total available organs. They assert that if all potential donors consented to donate their organs, there would not be a problem with supply. Although I do not have numbers, I strongly suspect that there are not enough people who die in intensive care units on life support who meet the strict definition of brain death. In order to have enough donors to meet the demand, I am afraid that we will have to move in a direction of being less concerned about being sure the donors have actually died (cf. Gen. 9:5-6), and this is already happening.

What began as a definition of death, based on whole brain death criteria, has been used somewhat loosely. For example, there is a 1987 study that demonstrates that many of the people in a position to apply the criteria did not know the criteria and applied it to test cases incorrectly.⁷  Since then, the confusion has not settled. A recent review in Community Ethics critiques three papers to prove the assertion that "the topic of brain death" is far from being a "resolved" ethical issue.⁸ I believe one of the reasons that it is not resolved is because of the pressure from the proponents of organ donation to define more people as potential donors.

There is pressure to move to a "higher-brain" rather than "whole brain" definition of brain death.⁹  Dr. Howsepian, a medical doctor who delivered an argu­ment against higher brain definitions of death, says,

There is a movement to try and redefine death, and make us think that somehow one can be dead even though one is moving, breathing, their hearts beating and there are brain waves on the EEG ... Robert Veatch has written extensively on this topic and is committed to try very hard to have people who are PVS or are demented in nursing homes, considered transplant donors.¹⁰ (PVS = Persistent Vegetative State. This is when a person is believed to be conscious but appears to be unconscious).

Another concern is that there is a movement to abolish the term "brain death."¹¹ The argument is that cardio­respiratory death is really only death after the brain dies. This is proved by the occasional success of CPR where the person's heart and breathing has stopped and is started again. It is suggested that this proves that "brain death" is the necessary ingredient, and that both the stiff body and the living body with a dead brain are equally dead. It is said that there are not two kinds of death and therefore both should simply be called "death."

Although there is an element of truth in this, there is a difference between a stiff, dead body with a dead brain and a living body with a dead brain. I hope to show you that a dead brain alone is not sufficient to define the death of the person and the term "brain death" is not equal to "death."

A final and alarming development is the use of "non-beating heart" donors. At first glance, this may appear to be similar to "clearly dead" donors. Remember that John Frame defined death in relation to the heart, the breathing and the brain. "Any of these may lose their function for a period of time and later be restored."¹²

I have not been able to obtain a clear description of what happens to a non-beating heart donor, although I found several references to it in medical journals. A CBS 60 Minutes story on non-beating heart donors' protocols from Ohio and Wisconsin said,

In cases where a terminally ill or fatally wounded patient is on a respirator, and the decision has been made to end mechanical support of respiration, the family may elect to donate their loved ones' organs. In such cases, a pre-approved formal protocol will be followed to recover the organs once the patient is declared dead through cardiac criteria.¹³

I believe that non-beating heart donors are patients who are unconscious in an intensive care unit who do not meet brain death criteria, yet the family and doctors have decided to harvest the organs. The patient is taken to the operating room and the ventilator is shut off, or the drug support to the heart is stopped. The doctors wait until the heart stops beating and then they start to retrieve the organs. In order for an organ to survive, the surgery needs to begin almost immediately after the heart has stopped. Has death occurred? Does the desire of people to find good in death and society's pressure to donate organs lead to giving up on a person's life prematurely?

Where do we draw the line as Christians? Can we accept "whole brain death" to be the same as the death of the whole person? We are to do all things according to Scripture. Yet, the Bible does not talk of death in terms of the brain. What Scriptural teachings can direct us in finding a definition of death? The teaching I have found most useful considers the Scriptural definition of personhood.

There are two divergent definitions of personhood, described by B. Holly Vautier, in her paper, Definition of Death. First, the inclusive understanding of personhood is the tradition that acknowledges the human being as a single entity having both a material body and an immaterial soul. This is founded on the Bible's record of creation when the Lord God formed man of the dust of the ground, and breathed into his nostrils the breath of life and man became a living soul.¹⁴

Louis Berkhof describes it this way: "Every act of man is seen as an act of the whole man. It is not the soul but man that sins; it is not the body but man that dies; and it is not merely the soul, but man, body and soul, that is redeemed by Christ." ¹⁵  The Heidelberg Catechism gives the same inclusive description of man: "That I with body and soul, both in life and death, am not my own, but belong unto my Saviour Jesus Christ."¹⁶

The other definition of personhood is the cognitive understanding of personhood, based on higher brain functions. Being able to separate the living body from the person, as must be done to justify removing organs from questionably dead donors, is based on this exclusive, rather than an inclusive, understanding of personhood. Holly Vautier writes,

Plato regards the body as evil — merely an impediment to the process of the soul. Descartes retains a mind/body dualism that reduces the status of the human body to that of a disposable piece of machinery. While the unified concept attributes goodness to the body, this view robs the body of all significance.¹⁷

She also states:

The prevailing moral ethos includes the value a cul­ture places on individual human life. Where a strong Judeo-Christian ethic is evident, for example, life is regarded as a gift and a trust. It is seen as an intrinsic rather than merely an instrumental good ... This sense of the sanctity or dignity of all human life has been influential in maintaining traditional western prohibitions against abortion, suicide, euthanasia, and haz­ardous medical experimentation on human subjects.

When an ethic, which endorses life for all persons, is replaced by an ethic of selective personhood, people are valued on conditional terms. Those who qualify for personhood (such as healthy, competent adults) retain their valued status in society. But those who fail to qualify for personhood (fetal life, disabled infants, incompetent adults, individuals who have lost their neocortical functions, for example) lose their status as valued members of the society. When loss of personhood is equated with worthlessness, depersonalization can too easily constitute a license to kill … Abortion is legal. The fiction of non-personhood ... has reached even beyond Roe v Wade. It has extended into the special care nursery, where Drs. Duff and Campbell have provided involuntary euthanasia for disabled new-borns. These physicians have publicly justified allowing death as a "management option" when "the hope of meaningful personhood" is absent.¹⁸

Vautier continues,

As medical technology advances, there will be an increasing temptation to depersonalize individuals and groups under the aegis of social needs. How we resolve the issue of personhood will determine when our social obligations to individuals begin and end. The classification of human beings as non-persons opens the door to a utilitarian ethics in which medical treatment is granted or denied on the basis of quality of life or economic criteria. Since a non-personhood policy implies that individual life is dispensable, it could lead to the sanctioning of the procurement of donor organs from dying patients.¹⁹

We must uphold the intrinsic value of each person. Psalm 139 teaches us that each unformed life in a mother's womb is important to God. We were individual persons from conception. This was before our brain was formed. According to God, the beginning of personhood on this earth is at conception. The development of the physical presence of the brain is not what makes us important as individuals to God.

If the development of the brain does not define personhood, is it right to claim that the death of the brain takes away our personhood? A true definition of personhood must include both body and soul. When the Preacher in Ecclesiastes describes death, he says, "then shall the dust return to the earth as it was: and the spirit shall return unto God who gave it"  ²⁰ The body and the soul, that define the person, are not separated until death. Although there is separation after death, what happens to the body remains connected to the person.²¹

How, then, can we say that a person has died when it is still possible to keep the body from beginning to decay and from returning to the dust of the ground? I believe that as long as the lifeblood continues to flow in the body, keeping the body from the grave, we cannot say that the soul has "returned unto God."²²

When I began this research I wondered whether organ donation was permissible as long as it could be demonstrated that the entire brain was truly dead. After consid­ering what I have learned, I must take a stand against using organs from persons until they are clearly dead, even though this means that many so-called, potentially useful organs will no longer be able to be harvested.