National

Why do some doctors anesthetize brain-dead patients?

by Kaoruko Aita

Tetsuo Furukawa, professor emeritus of neurology at Tokyo Medical and Dental School, is a rarity in Japan: a neurologist who has been crusading against the practice of transplanting organs from brain-dead donors. Furukawa worries that patients in a supposedly brain-dead state may nevertheless feel pain, or some lesser sensation, when the surgeon’s knife cuts into their bodies to procure organs.

This may come as a surprise to Japanese, for whom the notion of brain-death has become so common as to be rendered uncontroversial.

But “it has not been scientifically proven that brain-dead people are completely unconscious when they are classified as brain-dead,” Furukawa says. “It is possible that they cannot express what they feel in a way that can be detected by others through modern technology.”

Twice denied an opportunity to express his views at the annual meeting of the Japanese Society of Neurology, a nationwide organization for neurologists, Furukawa has found other occasions — including smaller medical meetings and gatherings of citizens groups — to tell people what he thinks.

“Some medical doctors quietly came up to me after my talk to tell me they share my view,” he said. “But they didn’t want to go public with it because it goes against the current trend of promoting organ transplants.”

Looking abroad, it becomes apparent that Furukawa is not alone in his opinion.

On Aug. 20, Britain’s Sunday Telegraph published an article by physician Philip Keep describing the ongoing debate in that country over concerns that brain-dead donors may feel pain while their organs are being removed.

The debate was started by the anesthesiologist at the Norfolk and Norwich Hospital, who wrote to Anaesthesia, the journal of the Royal College of Anaesthetists, claiming that many people in the medical profession feel uneasy about the issue.

“Nurses get really, really upset. You stick the knife in and the pulse and blood pressure shoot up. If you do not give anything at all, the patient will start moving and wriggling around and it’s impossible to do the operation. The surgeon has always asked us to paralyze the patient,” Keep said.

The physician criticized a guideline issued last year by Britain’s Intensive Care Society that anesthesia is not necessary to brain-dead organ donors.

Other anesthesiologists are also reportedly uneasy about the fact that brain monitors often show signs of activity in the higher brain when organs are being removed. At present, no one knows what these electrical impulses mean, the Telegraph reported.

Are Furukawa and Keep wrong to be concerned? Should doctors worry about the welfare of organ donors?

Keep is not the only physician to have remarked on the rise in blood pressure and heart rates when incisions are made in the bodies of brain-dead organ donors. These phenomena have been regularly reported in medical journals since the 1980s.

Michael DeVita, assistant medical director of the medical management division at the University of Pittsburgh Medical Center Presbyterian Hospital and a leader in the U.S. organ-transplant community, says that brain-dead organ donors are given anesthetics at most hospitals in the U.S., including the medical center he works for.

He stresses, however, that the purpose of administering narcotics is not to prevent donors from feeling pain but to prevent spinal reflexes from obstructing the operation.

“Spinal reflexes can cause a big increase and a decrease in blood pressure (and) ventricular tachycardia. (These) happen when you make an incision, even if the person has no brain function.

“It is not pain, but physiological responses to incisions. An anesthetic prevents them,” DeVita said, comparing the response to the way a finger will reflexively pull back when it is put into hot water.

“When you do it, you pull it back actually before it hurts. That is spinal reflex. It did not touch your brain. The initial response is not painful,” DeVita says. “It is an issue of physiology, not comfort. (Anesthesia) is not for the donor’s benefit; it is for the doctors and nurses working around the donor.”

DeVita rejects the possibility that brain-dead donors can feel any kind of sensation when an incision is made.

However, Nicholas Tilney, professor of surgery at Harvard Medical School and the director of renal-transplant services at Brigham and Women’s Hospital in Boston, Mass., says, “We do not give anesthetics to brain-dead donors, because we do not need to. I do not understand why some others do. Maybe to make sure that donors do not move. In my experience, (that) is very rare.”

Concurring with DeVita, Robert Peterfreund, anesthesiologist at Massachusetts General Hospital, another Harvard affiliate, said he has occasionally given an anesthetic to organ donors. “They would receive medications similar to what any patient undergoing surgery receives, because those medications, in addition to controlling pain, help us control heart rate, blood pressure and so forth,” he said.

Michael Bailin, another anesthesiologist at MGH, says he also gives anesthesia to brain-dead donors occasionally.

Asked why a brain-dead donor’s heart rate and blood pressure increase in response to incisions, Bailin said it is because the stimulation of the incision is processed by the spinal nerves running directly from the spinal cord, which is alive in brain-dead individuals.

“The pain pathway would be from the skin, the underlying muscles and tissue and the chest or abdominal cavity, and the pain will be brought to the spinal cord.

“At that point, the pain can run up the spinal cord and knock on the thalamus, which is the part of the brain that will radiate the pain signals to the cortex. But there is no cortical activity,” he said, rejecting the possibility that a donor could feel pain.

However, Bailin admits, there are no data on whether anesthesia is necessary.

“A lot of the anesthesia we give is not based on science. I believe much of the anesthetic practice that is currently used is based on clinical experience or anecdotes or someone’s opinion,” he says. “Scientific? No. Does the job? Yes,” he said.

Robert Truog, professor of anesthesiology and medical ethics at Harvard Medical School, says that since doctors have to convince everybody, including themselves, that donors are already dead, some of them think it does not make sense to give an anesthetic.

“I think if we accept, instead, that they are severely brain-damaged, that they are not going to recover, then I think it is more than an unknown question whether they may experience pain,” he says. “In my personal view, with that much brain damage, I am virtually certain that they don’t experience pain in a way you and I experience pain.

“Yet I can’t be certain that there might not be some sensation there. The change of the heart rate and blood pressure . . . raises questions. We don’t really know . . . and it is very unlikely we could do studies to find out one way or the other.

“So I would give anesthesia to an organ donor. It is cheap, it is easy, it does not hurt (the) organs at all. If there is a little part of the brain that is still able to experience something, we take care of that (with anesthesia). But we do have to remember that such patients have very, very little brain function. We are not talking about you and I having operation without anesthesia.”

Masao Ito, professor emeritus of neurophysiology at Tokyo University School of Medicine and now director of the Brain Science Institute of the Institute of Physical and Chemical Research in Wako, Saitama Prefecture, offered a cautionary final comment.

“I think that 99 out of 100 patients who are classified as brain-dead under the Japanese brain-death criteria, which are said to be the strictest in the world, feel absolutely nothing when their organs are removed. But I am not sure about the remaining one. (He or she) probably does not feel . . , but I cannot say for sure,” Ito said.