* When, if ever, and under what circumstances is it right to use for transplantation the tissues and organs of a hopelessly unconscious patient?

* Can society afford to discard the tissues and organs of the hopelessly unconscious patient when they could be used to restore the otherwise hopelessly ill but salvageable individual?

The ever-broadening experimentation in the transplantation of tissues and organs has already led to the use of organs of hopelessly unconscious patients while their hearts were still beating. The ethics of this have been questioned. There is, therefore, some urgency to face up to the problems mentioned.

I mentioned Judge Cooley's memorable phrase (1888) that there is "the right to be let alone." Implicit in this is the right to live and the right to die. There is also the opposite right, to communicate. The individual's right to be let alone conflicts with the advancement of that part of society which is based upon scientific research. The development of science requires reasonable freedom for the investigator; at the same time a healthy society imposes restraints on him for the sake of the individual. Thus tension exists between society and scientific man. "This tension between society and science extends to all disciplines in the social, physical and life sciences. It affects the practitioner as well as the research investigator." There is also the "...conflict of science and scientific research with the right ... of private personality."

These thoughts and others to come are relevant to this presentation because of the pressures to use the hope-lessly unconscious patient's tissues and organs in an attempt to help the otherwise hopelessly ill but still salvageable patient in certain experimental procedures.

The moment of death can have legal importance, but the criteria by which death is established must depend upon medical evidence. Granted that there may be a time when it is good, i.e., appropriate, to die -- but when is that moment? What are its criteria?

Starzl (1966, p. 98) has spoken of "the declining curve of life," implying that as the end approaches there is less and less life in the individual, that there is present quantitative factor, a sort of death by inches. To a certain point this is supportable in that all organ and never centers do not become irreversibly damaged simultaneously: consciousness as a brain function is often irretrievably destroyed months to years before the respiratory and vasomotor centers fail. At the same time one can share Schreiner's (1966, p. 100) disconent and insist that "a coordinating vital principle exists which is either there or not there." This vital principle comes into being when the sperm fertilizes the ovum and persists until life no longer is present. The moment of death can only be approximated.

From ancient times down to the recent past it was perfectly clear that when the respiration and heart stopped, the brain would die in a few minutes; so the obvious criterion of a heart in standstill as synonymous with death was accurate enough. This is no longer the case when modern resuscitative and supportive measures are involved. These improved activities can now restore "life" as judged by the ancient standards of persistent respiration and continuing heart beat. This can be the case even when there is not the remotest possibility of an individual recovering consciousness following massive brain damage. In other situations "life" can be maintained only by means of artificial respiration and electrical stimulation of the heart beat, or in temporarily by-passing the heart, or, in conjunction with these things, reducing with cold the body's oxygen requirement.

Or, to phrase it differently, death occurs at several levels. . . .

It is interesting that we have to ask the series of questions: When is death, what is death, what is life? It is self-evident that there is no simple answer to what life is. Quoting Dr. Zhivago as saying that we live solely in others, one can submit that life is the ability to communicate with others. . . .

Some have spoken of taking organs from a dying person. "I would like to make it clear [says Alexandre] that, in my opinion, there has never been and never will be any question of science and scientific research with who has "no reasonable chance of getting better or resuming consciousness." The question is of taking organs from a dead person, and the point is that I do not accept the cessation of heart beats as the indication of death." (Certainly such individuals have lost their ability to communicate. The question is, have they also lost their right to be let alone.) Their legal position depends entirely on what is determined to be the legal definition of death. . . .

It seems clear that any "updating" of the moment of death, in view of the differences among the experts who have given much thought to the matter, would be a legal impossibility at this time, however theologically and scientifically sound it might be. This is not to argue against "updating"; it is to suggest the propriety of caution. These are encouraging signs. Consider the following celebrated case.

In this case (E.D.R.S. and G.L.B.T, 1963) an inquest was held in Newcastle on a man who on being struck fell backwards onto his head. Respiration failed 14 hours after hospital admission and he was placed on a respirator. A day later, with his wife's consent, a kidney was removed for transplantation. Following the nephrectomy the respirator was turned off. There was no spontaneous respiration. A medical witness declared the man had virtually died at the time he was put on the respirator, although it was legally correct to say death occurred following the interruption of artificial respiration. The surgeon, described as an assailant, was charged by a jury with manslaughter. He was then committed for trial by the coroner. The coroner had consented to the nephrectomy in accordance with the Human Tissue Act, 1961, section 1(5) and the jury found that this had not contributed to death. In the discussion following, it was proposed that the moment of death be defined as the moment when spontaneous heart beat cannot be restored. Others (Louisell, 1966) raise the question of whether the moment of death might not best be defined as "the moment at which ireversible destruction of brain matter, with no possibility of regaining consciousness, is conclusively determined." . . .

. . . Vested interests impinge on most moral choices. This stuation is not difficult. It will be best to consider whence these pressures come. Their presence calls for caution.

First from the patient's point of view: If conscious, he is not obliged to avail himself of extraordinary means of survival. A good case in point is the use of intermittent hemodialysis for the man with kidney failure. At a recent symposium, "Ethics in Medical Progress" (edited by Wolstenholme and O'Connor, 1966) considerable discussion was devoted to the question of whether it is suicide for a man who has the opportunity to avail himself of intermittent hemodialysis to reject it. The answer is surely no: It is still experimental; the subject has the right to withdraw. It is an extraordinary process for maintaining life; therefore not obligatory. (Plus XII, 1957)