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Before the first kidney transplant in 1954, it didn't really matter precisely what time someone was declared dead. Doctors would wait until the corpse turned blue and started to stiffen before declaring death. There'd been enough stories of people waking up in their coffins for doctors to want to be really sure before declaring anyone dead.
The kidney transplant changed all that. Now that a corpse's organs could save someone else's life by being recycled, the problem of defining death became a lot stickier. As the New York Times put it:
Organ transplantation must abide by the so-called dead-donor rule: a person has to be declared dead before any vital organs can be removed. Yet organs have to be alive if there is any hope of successful transfer to a recipient. Medical professionals have handled this paradoxical situation - finding a dead body with live organs - by fashioning a category of people with beating hearts who are said to be brain-dead, usually after a traumatic head injury, and who are considered just as dead as if they had rigor mortis. [emphasis added]
It works like this. Suppose you've signed a donor card and you get tagged by an 18-wheeler in a crosswalk. If you're killed immediately, your donor card won't do anybody any good because your organs will spoil by the time the ambulance gets there.
Suppose, however, that the truck smashes your cerebral cortex, which houses your dreams, your consciousness, your personality, and your sense of who you are but leaves enough of the lower, nonthinking parts of your brain that you keep breathing and your heart keeps beating.
That's ideal - the EMTs stabilize you and find that you're "brain dead" even though your heart is still beating just fine. They can keep your heart supplying blood to your organs for quite a long time - Terry Schiavo's heart beat for years after her brain was effectively gone. They can measure your tissue type and collect the people at the top of the list for receiving transplants into the operating rooms right next to you.
They pull the plug at just the right time and immediately cut out your organs and install them in the waiting donors. If all goes well, they can recycle your heart, lungs, liver, kidneys, corneas, pancreas, and an ever-lengthening list of other organs including bits of bone and skin.
Unfortunately, it doesn't usually work that smoothly. First, no legislature has passed a law saying that unless you declare that you do not want to donate organs, they're free for the taking. Hospitals have to rely on people who opt-in by signing donor cards which relatively few people do in spite of years of publicity.
The nonprofit United Network for Organ Sharing (UNOS) web site lists people who're waiting for various kinds of organs. On an average day, they assert, about 18 people out of more than 100,000 who're waiting will die.
This statistic illustrates the outcome of rationing medical services - there simply aren't enough organs to go around. UNOS has a strict protocol for allocating organs as they come available and claims that nobody, but nobody, is able to jump the queue, at least not for now.
Queuing rules in England are so rigid that a dying woman was not permitted to donate her kidney to her daughter, who needed a new one but wasn't high up enough in the list. Since a person's body is part of the estate and is ordinarily subject to the terms of the will, the National Health Service in effect robbed the mother's corpse of a kidney that should've gone to her daughter.
This sort of bizarre outcome is a natural result of any medical shortage.
There's no way to know how many more organs would be available if people had to opt out by wearing a bracelet or necklace saying they did not want to donate organs instead of people having to opt in.
Even with donor cards, the number of fatal head injuries keeps going down as we improve safety throughout the country. How many times have we seen exhortations to wear helmets while riding a bike and even nanny-state laws attempting to require such impositions on liberty? Yet while a bike helmet might occasionally save the occasional life by protecting the head it also reduces the number of transplant-available organs that might otherwise come available, and previously would have.
The bottom line is that 18 people per day die while waiting for treatment and some putatively incorruptible group who's utterly immune to political pressure, bribery, or campaign contributions decides who gets organs as they become available. As with any medical rationing system, letting people die reduces demand enough that the supply becomes adequate to meet the remaining need.
Doctors don't enjoy seeing their patients croak while waiting in line; desperate docs call for desperate measures. The need for organs has become so acute that medical experts in New York City received a Federal grant to see if they could get more organs from people who die at home or in the street. In an attempt at more aggressive harvesting, they're deploying "rapid organ-recovery ambulances" which follow regular ambulances.
When someone dies, the organ wagon tries to stabilize the body long enough for the organs to be collected and kept in good shape while being handed off to waiting recipients. The organ wagon concept has created the unappetizing situation where you have one team of EMTs from the normal ambulance trying to save the patient and another team from the organ wagon waiting around like vultures: "Is he dead yet? Can we have him? He looks plenty dead to me!"
In a further effort to get more recyclable organs, doctors have put together another definition of death which lets them harvest organs from people who aren't brain-dead. The 1981 Uniform Determination of Death Act offers an alternative definition the "irreversible cessation of circulatory and respiratory functions."
If the patient shows enough brain function that they can't be declared brain-dead but is "certain enough" to die anyway, they can turn off the ventilator. If the patient's heart stop and stays stopped for some period of time, ranging from 1 to 5 minutes depending on the hospital's protocol, the patient has exhibited an "irreversible cessation of circulatory and respiratory functions" and organs can be harvested.
This opens a glaring ethical question - what if they're trying to recycle the heart itself? The whole point of transplanting a heart is to have it start up again in the recipient's body. How can anyone say that there's been an "irreversible cessation of circulatory and respiratory functions" if they're planning to restart the heart in someone else?
Regardless of this conundrum, doctors really don't like watching people die while waiting for organs, so this definition is slowly gaining ground as more and more hospitals come to accept it.
Having the heart stopped for 5 minutes traumatizes it and makes it much more difficult to restart after the transplant; being without fresh blood for that long isn't good for the other organs either. Some doctors are urging that the period be reduced to one minute or even less. Ethicists have pointed out that this is a back-door to euthanasia which can be justified only on the ground of saving lives by recycling organs.
As deliberately-induced "heart death" has become more common, doctors have found that injecting drugs such as herapin into the patient increases blood flow to the organs and keeps them alive longer. Injecting herapin and clot-suppression drugs doesn't help the dying patient at all; the sole purpose of this "treatment" is to benefit the recipient after the organs are recycled.
Some point out that it's ethically questionable to give a treatment that's known not to benefit the patient who's being treated. Others shrug off the question as not mattering since the person is "as good as dead" and will in fact be dead once the respirator is shut down; they argue that the social good done for the recipient is paramount, after all, the donor is so nearly dead that life isn't worth anything.
The situation is so ambiguous that some say that the whole notion that the moment of death can be clearly defined is nothing more than a necessary fiction. Like the fiction that the TSA deters hijacking makes people feel safe enough to fly, the fiction of not harvesting organs until the donor dies helps keep people from objecting to the entire concept of harvesting organs enough to outlaw it or to stop signing donor cards out of fear that they'll be killed prematurely.
We've been down this road before. Early in the 20th century, the eugenics movement declared that some people were unfit to reproduce and should be sterilized whether they wanted children or not. Hundreds of thousands were sterilized before WW II gave the eugenics movement a bad name.
Most of the arguments favoring sterilizing "defective" people because their genes were not worth preserving sound eerily like the arguments for harvesting organs from disabled or dying patients because their lives aren't worth preserving.
The other argument for sterilizing people was that supporting their defective children would cost too much. This, too, is similar to the arguments against treating certain classes of sick people because curing them would cost too much and using their organs to save other people's lives is so beneficial to society as a whole. This sounds like the slogan, "The common good before the private good" which we've heard so often before.
The health care law being bandied about in the Senate and the House will solve the organ donor problem, of course. It gives a new health care bureaucracy the power to decree which treatments you receive based on your age, the cost of treating you, and the value of your future years of life. If the bureaucrats think you're damaged "badly enough" or that treating you will "cost too much," they'll be able to declare that the only treatment you get is what's needed to preserve your organs for donation.
They'll chop the heart-stopped time down to something reasonable, like, say, 15 seconds, even though hearts have been known to restart spontaneously after as long as 65 seconds of silence. They'll change the "dead donor rule" to "nearly dead." They'll change organ donor sign-up from out-in to opt-out which, along with a much lower standard for declaring a patient ready for recycling, will greatly reduce the organ shortage.
Once your organs have been harvested, you're no longer a voter, but the lucky beneficiary most certainly is. The politicians will claim credit for providing more organs to people in need, the media will ignore any ethical lapses, and nobody will ever know how many people would have lived if the bureaucrats hadn't been so all-fired hasty about pulling the plug.