Organ transplantation as a process has many players and a lot of moving parts. For example, there is the donor and the donor’s family, the recipient and family, social workers, pharmacists, myriad specialists, surgeons, and the national, regional, and local governing bodies that procure and allocate organs. All of these moving parts lead to significant specialization on the parts of the players involved, while also creating openings for ethical problems at every step in the process. There are questions about who gets listed to get an organ, how they pay for it, where the organ comes from, who isn’t getting the organ, are regions getting similar numbers or organs….I could continue listing questions for paragraphs, but I want to hone in on one question in particular: How are the bodies of donors and recipients conceptualized in this medical setting.
At Northwestern this year, I have presented myself as both a chaplain and ethicist. Clinically, I see patients—mainly transplant patients—and talk to them about existential and religious issues that are prompted by their illnesses and treatments. As an ethicist, I have sat in on a few consults, but for the most part, I spend a lot of time in my head thinking about the relationship between science and the humanities. Notably, my specialization allows me complete freedom of movement within the patient population that I see. Sure, I respond to patient needs, but I don’t spend all day doing procedures or managing medications; I am free to engage with patients on different terms, humanistic terms, and to see the families of donors, living donors, and recipients. In short, my position gives me the freedom and access to have a bird’s eye view of the transplant process.
With that access and freedom, I’d like to offer an observation and talk about its potential implications. The observation: donor bodies and recipient bodies are conceptualized differently. Dead donors are bodies without interior lives to be recovered, while potential recipients are bodies that are seeking a psycho-somatic unity; in short, the long-standing mind-body dualism shows up in the transplant process, especially with respect to the donor, but is challenged by the condition and potential recovery of the recipient. To fully explain how the mind-body dualism rears its head in these situations, some background in transplantation is necessary.
There are two kinds of organ donors: living and deceased. I am only talking about deceased donors. Within deceased donors, there are two ways to die—cardiac death and brain death, with the latter being preferred. In cardiac death, the heart stops and the blood supply to the organs stops. In brain death, the brain can no longer maintain the necessary functions of life, but often patients in this condition are in the hospital and are on life support, meaning that machines have taken over the functions necessary to maintain life. Visually, that means that the brain dead patient appears alive to family and friends: the machines register a heartbeat, the body is warm, the lungs move up and down. But there is no possibility of the brain ever being able to take over those functions again or ever recover higher functions, such as the ability to communicate. The brain dead patient is the ideal organ donor because her organs continue to be supported by machines. In contrast, the donor who dies because her heart stops has organs that start to show the deteriorating signs of her death much earlier and are therefore less optimal organs for transplantation. Visually, the cardiac death donor appears dead; there is no heartbeat, the lungs do not move up and down, the body starts to lose heat and color quickly. To family and friends, the cardiac death patient appears dead.
For the purposes of thinking about mind-body dualism I will focus on the brain dead donor, who is dead, but shows signs of life. These donors have a body, but no mind. In fact, their minds are irrecoverable and they are permanently just a body. It is often hard for patients’ loved ones to accept this state of affairs. The language that I have heard from families and medical staff attending to these patients is, “She’s gone,” or “She’s not in there anymore,” or “He’s not coming back.” The mind, soul, whatever makes a person a person is no longer present; it has gone away to another place. No one is very specific, not even the chaplains, about where the person-making aspect goes, but the theory of the body is pretty clear—the body is material that is animated by something.
To consider how recipients factor in to the mind-body dualism, I’ll consider End Stage Liver Disease patients specifically. These patients have livers that are failing and there is no therapy available other than a liver transplant. They suffer many complications from their disease, and one of them is Hepatic Encephalopathy—they end up mentally confused because their livers are not working. The main treatment for this mental confusion is a liver transplant, thus the mind and body are yoked together in the liver recipient. Getting a new liver will clear up the mental confusion in the patient.
With the donor, there is no physical treatment that will bring the mind back, but with the recipient there is. You may be thinking, “Isn’t that just the difference between being alive and dead?” Well, maybe, but with this particular type of liver recipient, it is clear that the patient’s mental activities are biologically affected, while with the brain dead donor biological activity no longer affects the mind; her mind is beyond reach of physical effects. The donor’s situation represents a classical example of mind-body dualism: there are no material (or bodily) explanations for mental states. The recipient’s mental confusion prompts a reassessment of that claim because there is only a material explanation for the mental confusion that she experiences.
As with many aspects of organ transplantation and medical ethics, pragmatism wins out. These definitions of the donor and recipient ‘work.’ It is helpful for us to think of the brain dead donor as biological matter without a mind, while at the same time recognizing that for the recipient there is a psycho-somatic unity that can be recovered. But my theological and ethical training makes me uneasy with definitions of the human that change to match the context. What would a consistent definition be, and how would it affect medical practices? Are medical practices bits of evidence to force a reassessment of philosophical and theological thinking? I don’t know, but I’m going to keep thinking.