Christiaan Neethling Barnard

Dr C. Barnard Christiaan Neethling Barnard ( * 8 de noviembre de 1922 - 2 de septiembre de 2001) fue un mdico ciru ano sudafricano descendiente de !as fami!ias escocesas Ba!io! " Barnard. #studi$ " se doctor$ en !a %niversidad de Ciudad de! Cabo. Curs$ medicina en !a %niversidad de &#! Cabo&' donde se (radu$ en 19)*. #mpe+$ su carrera como mdico ciru ano (enera! en e! ,ospita! -roote .c,uur' de Ciudad de! Cabo' donde su ,ermano ma"or /arius era efe de! e0uipo de trasp!antes. #n 19)) obtuvo una beca para in(resar en !a %niversidad estadounidense de /innesota' donde en 19)8 obtuvo e! t1tu!o de doctor especia!ista en cardio!o(1a. 2!!1 fue a!umno aventa ado de! presti(ioso doctor 34en 5. 6an(esteen' 0ue !e introdu o en !a ciencia cardiovascu!ar' mientras 0ue e! doctor .,um4a" !e fami!iari+$ con !a tcnica de trasp!antes de cora+$n en anima!es' por !o 0ue' a su re(reso de #stados %nidos' empe+$ a practicar durante varios a7os con perros. #n 1982 fue nombrado efe de ciru(1a tor9cica de! ,ospita! -roote .c,uur' donde "a ,ab1a e ercido antes de doctorarse. 5ab1a e:perimentado durante varios a7os con trasp!antes en cora+$n de anima!es' despus de! primer :ito de trasp!ante de ri7$n en 19);. Barnard rea!i+$ e! primer trasp!ante de ri7$n en .ud9frica en 19)9. <os trasp!antes de $r(anos no eran una novedad en a0ue! momento. #! primer trasp!ante rena! !o rea!i+$ e! doctor =aron" en 19*8. #n 19)*' 5ard" rea!i+$ e! primer trasp!ante de pu!m$n a un paciente afecto de c9ncer' " en 19); /urra" !o(r$ trasp!antar con :ito !os ri7ones de dos (eme!os' rea!i+ando en 198> un trip!e trasp!ante de ri7$n' p9ncreas " duodeno. #n 198;' e! mencionado 5ard" trasp!ant$ e! cora+$n de un c,impanc a un ,ombre' 0ue fa!!eci$ a! cabo de una ,ora por e! menor vo!umen de! $r(ano de! simio. ?nicia!mente traba a en e! ,ospita! -rooter .c,urr de Ciudad de! Cabo' " posteriormente se tras!ada a #stados %nidos donde se especia!i+a en ciru(1a cardiovascu!ar. @ue profesor de !a %niversidad de Ciudad de! Cabo desde 198*' " mundia!mente conocido por rea!i+ar e! * de diciembre de 198> e! primer trasp!ante de cora+$n en !a ,istoria de !a ciru(1a. #se * de diciembre de 198>' una noticia 0ue reco(ieron todos !os te!etipos asombr$ a! mundoA un mdico sudafricano ,ab1a rea!i+ado e! primer trasp!ante de cora+$n a un ser ,umano. #! receptor fue <ouis 6as,BansB"' comerciante' ,ombre corpu!ento "

optimista de cincuenta " seis a7os' desa,uciado por un irreversib!e prob!ema card1aco' a! 0ue se un1a una diabetes a(uda. <a donante' Dnise Darva!!' una oven oficinista de veinticinco a7os atrope!!ada unto a su madre por un autom$vi!. <a operaci$n' !!evada a cabo por un e0uipo de veinte ciru anos ba o !a direcci$n de Barnard' dur$ seis ,oras. 2! despertarse' 6as,BansB" dec!ar$ 0ue se sent1a muc,o me or con e! nuevo cora+$n. /dico " paciente sa!ieron catapu!tados ,acia !a fama' aun0ue diecioc,o d1as despus' !a madru(ada de! 21 de diciembre' e! paciente muri$ de una neumon1a' inducida por e! tratamiento inmunosupresor 0ue deb1a tomar. #! 2 de enero de 1988 rea!i+$ e! se(undo trasp!ante. #sta ve+ e! receptor fue e! doctor C,i!ip B!aiber(' " e! donante' e! mu!ato C!ive 5aupt. #! cora+$n de un ne(ro !ati$ durante )8* d1as en e! cuerpo de un b!anco. 2 partir de a0ue! momento' en medio de una po!mica 0ue no cesaba respecto a !a biotica de ta!es intervenciones (Dest9 muerto e! 0ue no respira pero su cora+$n !ateE)' !os pacientes fueron (anando e:pectativas de vida' (racias a !os f9rmacos inmunosupresores como !a cic!osperina. #n 19>0 se divorci$ de su primera esposa' <ou4t ie' 0ue !e ,ab1a dado dos ,i osA 2ndr' 0ue se suicidar1a en 198; a causa de !a separaci$n de sus padres (se(Fn dia(n$stico de su psi0uiatra " apreciaci$n de! propio pro(enitor)' " Deirdre. 20ue! mismo a7o se cas$ con !a rica ,eredera Barbara Goe!!ner' de diecinueve a7os' ,i a de! mu!timi!!onario a!em9n @redericB Goe!!ner' afincado en Ho,annesbur(o " conocido como e! Ire" de! aceroJ. #n 19>; rea!i+$ por primera ve+ en e! mundo un dob!e trasp!ante de cora+$n' 0ue consisti$ en a7adir un cora+$n m9s sano a otro enfermo para a"udar!e a cump!ir !as funciones de! 0ue "a ten1a. Cero sus e:perimentos en e! 0uir$fano terminar1an' tarde o temprano' en fracaso. #n 19>)' cuando empe+aba a dec!inar su fama' visit$ #spa7a para presentar su !ibro Kensi$n' " a su nueva esposa (0ue !e ,ab1a dado dos ,i os' @redericB " C,ristian)' con e! prop$sito de no perder un 9pice de popu!aridad en !a cuenca mediterr9nea' donde era m9s adu!ado. Continu$ rea!i+ando trasp!antes de cora+$n. #n 19>9' sin embar(o' se ne($ a participar en una operaci$n de trasp!ante de cabe+a ,umana por encontrar !a idea impracticab!e "' Iprobab!emente' inmora!J. #sta afirmaci$n !e sa!va(uard$ e! ,onor.

Obra
2utor de nove!as comoA

Tensin Tiempo de nacer, tiempo de morir #! Donante .u .a!udab!e Cora+$n #staci$n Locturna <a /e or /edicina

/anua! de 2rtritisA como vivir con artritis .ud9fricaA disecci$n )0 modos de tener un cora+$n sa!udab!e <a /90uina de! cuerpo

#n 1981' a7o en 0ue promov1a su !ibro <a m90uina de! cuerpo' !a artritis 0ue padec1a desde 19)8 se a(rav$ ,asta impedir!e e! e ercicio de su profesi$n sin (raves ries(os para e! paciente. Kambin en !os a7os oc,enta' su esposa Barbara puso fin a su matrimonio " se cas$ posteriormente con un ,ombre de ne(ocios portu(us. Barnard intent$ re,acer su vida con !a mode!o #ve!"n #nt!eder' de veinticuatro a7os' 0uien !o abandon$ tambin. @ina!mente' encontr$ e! e0ui!ibrio sentimenta! con otra mode!o cuarenta " un a7os m9s oven 0ue !' Maren .et+Born' con !a 0ue contra o matrimonio en 198* " con !a 0ue tendr1a dos ,i os m9s' 2rmin " <ara' 0ue naci$ cuando Barnard contaba setenta " cuatro a7os de edad. #n 198*' despus de traba ar en un ,ospita! de #stados %nidos' abandon$ definitivamente e! e ercicio de !a ciru(1a' pero a pesar de !os ac,a0ues' e! despresti(io entre sus co!e(as " !a prdida de popu!aridad' intent$ abrirse nuevos caminos. 5asta entonces ,ab1a rea!i+ado a!rededor de 1;0 trasp!antes' entre e!!os e! de! cora+$n de un mandri! a una enferma de veinticinco a7os 0ue muri$ a !as pocas ,oras. 2 partir de 198> se dedic$ a !a investi(aci$n mdica " diri(i$ cuatro e0uipos en e! ?nstituto /a: C!ancB " en !a %niversidad de 5eide!ber(' ambos en 2!emania' un tercero en !a %niversidad de 3B!a,oma' en #stados %nidos' "' por F!timo' otro en .ui+a. #sos e0uipos rea!i+aron estudios orientados a descubrir !as causas de! enve ecimiento de !os or(anismos " !os factores bio!$(icos presentes en e! feto " 0ue desaparecen a! nacer ste. 2dem9s de coordinar esos e0uipos' se ocup$ de su inmensa (ran a de ove as cerca de Ciudad de! Cabo' donde' adem9s' intent$ reintroducir anima!es sa!va es 0ue ori(inariamente ocupaban a0ue!!os para es. #n 199* pub!ic$ su autobio(raf1a' La segunda vida' donde adem9s de ,ab!ar de su tra"ectoria profesiona! e:pon1a con deta!!e sus idi!ios con mu eres famosas. #n sus via es " conferencias insist1a en !o 0ue fue !a obsesi$n de sus F!timos d1asA incu!car a !a sociedad !a necesidad de !a donaci$n de $r(anos. #n mar+o de 2001 aFn dio muestras de prota(onismo a! pub!icar Cincuenta frmulas para un corazn sano. #! 2 de septiembre fa!!ec1a en C,ipre a !os setenta " oc,o a7os de edad' v1ctima de un ata0ue de asma' no de un ata0ue card1aco como pub!ic$ !a prensa a !as pocas ,oras de! fa!!ecimiento. #se mismo a7o' e! imp!ante en un paciente estadounidense de! cora+$n artificia! 2biocor como un $r(ano permanente constitu"$ un ,ito 0ue empe0ue7ec1a de a!(Fn modo !a proe+a rea!i+ada por Barnard en 198>

Christiaan Barnard: his first transplants and their impact on concepts of death
Raymond Hoffenberg, retired physician
304/57A Newstead Terrace, Brisbane, Q eens!and 400", A stra!ia This article has been corrected. #ee B$%& '00' (ebr ary '3) 3'4*7335+, 4"5&

T-is artic!e -as been cited by ot-er artic!es in .$/&

T-e deat- of /-ristiaan Barnard -as re0i0ed some 1ersona! memories& $ore im1ortant!y, it reminds s t-at -is o1erations at t-e end of 23"7 initiated t-e 1rod ction of a set of !ega! and 1-i!oso1-ica! 4 stifications for t-e remo0a! of a beating -eart from a 1ros1ecti0e donor& T-irty fo r years !ater t-ey remain a to1ic of contro0ersy&

Summary points

5n 23"7, w-en /-ristiaan Barnard carried o t t-e first - man -eart trans1!ants, t-ere were no g ide!ines for t-e diagnosis of deat- of beating -eart donors T-e re!ati0e s ccess of Barnard6s second -eart trans1!ant was fo!!owed by a 1eriod of ncontro!!ed co1ycat o1erations in many co ntries, wit- 1redictab!y 1oor res !ts T-e 78 definition of brainstem deat-, introd ced by t-e /onference of Roya! /o!!eges and t-eir (ac !ties in 237", -as 1ro0ed re!iab!e and rob st in c!inica! 1ractice

9n 3 :ecember 23"7 t-e -eart of a yo ng fema!e accident 0ictim was trans1!anted into a midd!e aged man s ffering from intractab!e -eart fai! re ca sed by coronary artery disease& He died 2; days !ater from e<tensi0e bi!atera! 1ne monia& T-is !imited s ccess was -ai!ed t-ro g-o t t-e wor!d as a ma4or medica! tri m1-, t rned Barnard into an internationa! s 1erstar, and 1ro0ided t-e im1et s for -im to try it again& His second s b4ect, :r .-i!i1 B!aiberg, was gi0en a -eart trans1!ant !ess t-an two wee=s !ater, w-ic- brings me to t-e 0ery minor ro!e 5 1!ayed in t-e w-o!e saga& T-e >donor,? a yo ng man w-o -ad -ad a se0ere s barac-noid -aemorr-age w-i!e bat-ing in t-e sea, was admitted nder my care& He was, in fact, t-e !ast 1atient 5 was 1ermitted to admit to @roote #cr Hos1ita! in /a1e Town& A go0ernment banning order * nder t-e b!an=et ># 11ression of /omm nism Act?+ inc! ded a c!a se t-at sto11ed me from teac-ing or entering any ed cationa! instit tion& T-is came into effect ne<t morning&

9n my !ast nig-t as t-e cons !tant onAca!! 5 was as=ed by t-e trans1!ant team to 1rono nce t-e man >dead? and confirm t-at -is -eart wo !d be s itab!e for trans1!antation& Any misgi0ings 5 mig-t -a0e fe!t abo t dec!aring someone dead w-i!e -is -eart was sti!! beating were confo nded by t-e t-o g-t t-at -esitation on my 1artB a recognised o11onent of t-e go0ernmentBmig-t be constr ed as an attem1t to ndermine t-e 1restige t-at Barnard6s e<1!oit -ad conferred on t-e co ntry& :es1ite t-is, 5 -esitated& $y 1atient sti!! -ad a few e!icitab!e ne ro!ogica! ref!e<es& 5 went -ome, ret rned an -o r or two !ater, sti!! fo nd t-e ref!e<es, and dec!ined to 1rono nce -im dead& At t-is stage t-e trans1!ant team was waiting in t-e wings and was c!ear!y dismayed at my 0erdict& T-e 1rofessor of s rgery *not Barnard, a!t-o g- -e was 1resent+ came 1 and said, >@od Cit so nds better wit- a g tt ra! Afri=aans 1ron nciationD, Bi!!, w-at sort of -eart are yo going to gi0e sE? 5 said 5 co !d not agree to t-e remo0a! of t-e -eart from someone w-o sti!! s-owed signs of >!ife,? and t-en s1ent a s!ee1!ess nig-t wondering w-et-er 5 was being nnecessari!y obstr cti0e& 5 went to t-e -os1ita! 0ery ear!y ne<t morning and satisfied myse!f t-at 5 co !d no !onger e!icit t-e ref!e<es, and t-e s rgery went a-ead& :r B!aiberg !i0ed for 2; mont-s wit- -is new -eart& 5t was t-e s ccess of t-is o1eration t-at sec red t-e f t re of -eart trans1!ants& Had it fai!ed, 5 s s1ect f rt-er attem1ts wo !d -a0e been deferred for some years& As a footnote, a!t-o g- t-e o1eration a!most certain!y e<tended B!aiberg6s !ife, t-e F a!ity of t-e e<tension was F estionab!e& :es1ite re1orts of -is ret rn to norma! !ifeB inc! ding 1ress re1orts of -is 1rom1t res m1tion of se< a! interco rse wit- -is wifeB-e was !eft wit- considerab!e disabi!ity& A syndicated 1-otogra1- of -im !ying in t-e sea -a11i!y s1!as-ing in t-e wa0es a11eared in t-e wor!d6s 1ress as testimony to -is remar=ab!e reco0ery& T-e disting is-ed 1o!itician He!en # Gman to!d me t-at s-e -ad, by c-ance, ta=en a stro!! a!ong t-e same beac- t-at day and st mb!ed on B!aiberg6s 0ent re into t-e sea& He was carried into t-e water, t-e ento rage ste11ed bac=, cameras f!as-ed, and -e was -a !ed o t before -e disa11eared -e!1!ess!y nder t-e wa0es& H-en 1eo1!e -a0e become aware of my rat-er ten o s connection wit- Barnard6s e<1!oit 5 -a0e often been as=ed w-y t-e wor!d6s first -eart trans1!ant came to be carried o t in /a1e Town rat-er t-an one of t-e !eading centres in t-e 7nited #tates or I ro1e& T-e first 1oint to ma=e is t-at t-e standard of medicine in /a1e Town in t-e 23"0s was ad0anced and so1-isticated& T-ere were we!! eF i11ed researc!aboratories and an et-os in w-ic- researc- and initiati0e were enco raged& T-ere was

a !arge com1!ement of f !! time doctors w-o combined t-eir c!inica! care and teac-ing in @roote #cr Hos1ita! wit- e<1erimenta! wor= in t-e ad4acent medica! sc-oo!& A fr itf ! 1artners-i1 e<isted between t-e 1ro0incia! administration w-ic- ran t-e -os1ita! ser0ices and t-e ni0ersity, simi!ar to t-e >=noc=AforA=noc=? agreement t-at so 1rofitab!y c-aracterised Britis- medicine nti! t-e 1ast decade or so& ( !! time academic staff were s1onsored to go on o0erseas 0isits to =ee1 abreast of new ad0ances and disseminate t-eir =now!edge on t-eir ret rn& T-ere was e<ce!!ent co!!aboration between de1artments, c!inica!!y and in researc-, notab!y in cardio!ogy, in w-ic- an o tstanding team of 1-ysicians wor=ed c!ose!y wit- a strong s rgica! team -eaded by Barnard& /a1e Town was by no means an academic bac=water, t-e en0ironment was cond ci0e to inno0ation& H-at was re!ati0e!y n s a! was t-e 1resence in t-e medica! sc-oo! of a strong de1artment of e<1erimenta! s rgery, fo nded wit- remar=ab!e 1ers1icacity some 30 years ear!ier& 5n 235; Barnard was a11ointed as its -ead, and -e began to de0e!o1 an ambitio s 1rogramme of o1en -eart s rgery& He was egocentric, -ardwor=ing, c!e0er, ambitio s, bras-, and somew-at arrogant) -e f nctioned on t-e 1rinci1!e t-at anyt-ing ot-ers co !d do -e co !d do at !east as we!!& H-en a re1ort a11eared t-at a R ssian s rgeon -ad grafted a second -ead on to a dog, Barnard immediate!y did t-e same t-ing, a grotesF e accom1!is-ment -e 1ro d!y dis1!ayed to t-ose of s w-o were in t-e medica! sc-oo! at t-e time& T-ere was no c!ear 1 r1ose to t-is ot-er t-an to s-ow -is tec-nica! 0irt osity& By t-e !ate 23"0s se0era! 7# cardiac s rgeons, notab!y Norman #- mway, -ad s1ent years trying to 1erfect -eart trans1!antation, !arge!y t-ro g- e<1eriments on dogs& T-ey were ready to transfer t-e o1eration to - mans b t were concerned abo t t-e et-ics and, more im1ortant!y, t-e !ega!ity of >=i!!ing? a 1erson by remo0ing t-e -eart& 5n com1arison, Barnard6s 1re1aratory e<1erimenta! wor= in -eart trans1!antation was neg!igib!e, and many Americans to t-is day t-in= -e 4 m1ed t-e g n to get a-ead of t-e front r nners in t-e fie!d& T-e o1eration itse!f was not considered tec-nica!!y diffic !t com1ared wit-, say, s rgery to re1air com1!e< congenita! cardiac deformity& H-at in-ibited 7# s rgeons were et-ica! and !ega! considerations rat-er t-an tec-nica! s=i!!& 91inion in #o t- Africa was more 1ermissi0e, t-e remo0a! of t-e -eart did not aro se s c- strong fee!ings of ab-orrence, t-ere was !ess !i=e!i-ood of criticism t-at t-is wo !d, in fact, >=i!!? t-e donor& (ewer F estions wo !d -a0e been as=ed and t-ere wo !d -a0e been !ess acco ntabi!ity -ad t-e o1eration fai!ed& And, in Barnard, #o tAfrica -ad a man w-o was 1re1ared to act and t-en face t-e conseF ences&

His ac-ie0ement was -ai!ed as a nearAmirac!e& To t-e #o t- African go0ernment, facing great criticism and t-e t-reat of ostracism beca se of its in- mane a1art-eid 1o!icies, it was a godsend& T-ings co !dn6t be too bad in a co ntry t-at 1rod ced s can o tstanding first in medicine& 9n 30 :ecember 23"7Bwit-in a few wee=s of t-e first o1eration and time!y eno g- to re1ort t-e reci1ient6s deat- and necro1sy findingsBa s1ecia! iss e of t-e South African Medical Journal ce!ebrated t-e e0ent&2 5t contained a doGen artic!es and editoria!s abo t a!! as1ects of t-e o1eration& #ignificant!y, a1art from a few editoria! genera!isations, t-ere was no mention of t-e et-ica! or e0en !ega! iss es s rro nding remo0a! of t-e -eart from t-e donor and no s ggestion t-at s-e mig-t -a0e been regarded as !i0ing w-en s-e was ta=en into t-eatre for remo0a! of -er -eart& 5t -as been 1ost !ated t-at t-e reason w-y t-e o1eration co !d so easi!y ta=e 1!ace in #o t- Africa was t-e c!imate of re!ati0e disregard for - man !ife& H-i!e t-is mig-t -a0e been tr e in certain conte<ts, it did not e<ist to any materia! degree in t-e medica! wor!d and certain!y not at @roote #cr Hos1ita!, w-ere a!! races recei0ed treatment of t-e -ig-est standard& 5n considering a donor for t-e first o1eration great care was ta=en to se!ect a w-ite 1erson to ob0iate t-e criticism t-at wo !d s re!y -a0e fo!!owed -ad t-e -eart of a b!ac= 1erson been ta=en for a w-ite reci1ient& $ c- damage was done to t-e image of -eart trans1!antation by t-e immediate nseem!y scramb!e to get on t-e bandwagon& 5n 23";, t-e year after Barnard6s two o1erations, 207 trans1!ants were carried o t by "4 s rgica! teams in '4 co ntries& T-e res !ts were 1redictab!y bad, o1erations were 1erformed by i!!Atrained s rgeons wit-o t 1ro1er bac= 1, matc-ing of donors and reci1ients was 1oor, t-ere was !itt!e a11reciation of t-e need for metic !o s aftercare and t-e management of re4ection& Added to t-is was t-e e<traordinary -y1e accorded to t-e o1eration by t-e media, w-ic- was not e<act!y disco raged by some of t-e =ey fig res& Barnard -imse!f ind !ged in a rat-er im1et o s, f!amboyant, and ndignified g!oba! >!a1 of -ono r&? *H-en -e ret rned to #o t- Africa -e was instr cted by t-e go0ernment to re1eat t-e tri1, t-is time accom1anied by -is wife and s b4ect to a more sedate 1rogramme !aid down in ad0ance&+ 5n Jondon a cardiac team !ed by anot-er /a1e Town grad ate, :ona!d Ross, was 1-otogra1-ed for t-e news1a1ers -a0ing 1erformed a co1ycat o1eration *wit- fata! o tcome+, bearing a!oft a 7nion %ac= and a 1oster saying >He6re bac=ing Britain&? @rad a!!y t-e circ s as1ects s bsided, and a few 1ro1er!y trained s rgeons wor=ing wit- good s 11ort teams sett!ed down to s-ow t-at t-e o1eration co !d be done safe!y, sa0ing many !i0es t-at wo !d ot-erwise -a0e been !ost&

At t-e same time, disF iet was e<1ressed abo t t-e 1ro1riety of trans1!anting t-e -eart& 5n 1eo1!e6s minds t-is organ was endowed wit- a!most mystica! F a!itiesBit was t-e seat of !o0e and ot-er emotions, and disa11ointed !o0ers died of a >bro=en -eart&? 5ts transfer from one 1erson to anot-er was regarded as an nnat ra! act, medd!ing wit- >1erson-ood? and tres1assing into territory t-at -ad a s1irit a! F a!ity& $a!co!m $ ggeridge referred to it as >t-e fina! degradation of o r /-ristian way of !ife&? A1art from t-ese s1ecia! F a!ities, t-e -eart was c!ose!y associated wit- conce1ts of !ife and deat-, if it was beating t-e 1erson was a!i0e, w-en it sto11ed t-e 1erson was dead& Not-ing co !d be more fina! t-an its remo0a!Band t-e 1rocess of remo0a!, by w-ic- !ife was terminated, began to worry more t-o g-tf ! critics& Bot- of Barnard6s trans1!antations were 1erformed in :ecember 23"7& 5n #e1tember of t-e fo!!owing year an ad -oc committee of Har0ard $edica! #c-oo! 1rod ced a re1ort on t-e >-o1e!ess!y nconscio s 1atient&?' T-e committee members agreed t-at !ife s 11ort co !d be wit-drawn from 1atients diagnosed wit- >irre0ersib!e coma? or >brain deat-? *terms t-ey sed interc-angeab!y+ and t-at, wit- a11ro1riate consent, t-eir organs co !d be remo0ed for trans1!antation& T-ey stressed t-at t-eir 1rimary concern was to 1ro0ide an acce1tab!e mec-anism to 1ermit wit-drawa! of !ife s 11ort from s c1atients, and t-e sanction t-is ga0e to remo0a! of t-e -eart for trans1!antation was secondary& Howe0er, t-e 1rob!em of terminating !ife s 11ort -ad 0e<ed 1-ysicians for a decade or moreBe0er since it -ad become 1ossib!e to maintain cardiac, res1iratory, and metabo!ic f nctions a!most indefinite!y in 1rofo nd!y and irre0ersib!y nconscio s 1atients& T-e timing of t-e re1ort so soon after t-e -eart trans1!ant s ggests t-at t-is was 11ermost in t-eir minds& A con4oined !ega! o1inion ad0ised t-at 1atients w-o satisfied t-e criteria of brain deat- s-o !d be 1rono nced dead before organ remo0a! was attem1ted& T-e recommendations of t-e Har0ard re1ort were gratef !!y ado1ted by many a t-orities w-o were faced wit- t-ese 1rob!ems& B t t-e !ac= of 1recision in t-e definition of brain deat- ca sed considerab!e conf sion& To dea! wit- t-is a 7# .resident6s /ommission was a11ointed, w-ic- dec!ared in 23;2 t-at indi0id a! deatde1ended on eit-er irre0ersib!e cessation of circ !atory and res1iratory f nctions or irre0ersib!e cessation of a!! f nctions of t-e entire brain&3 A 7niform :etermination of :eat- Act insisted on >w-o!e brain deat-? as a sine F a non of brain deat-& T-is dec!aration was !ater enacted into !aw and -as been acce1ted by a!most a!! 7# states& B t it contin es to ca se 1rob!ems& Ta=en !itera!!y, it wo !d mean t-at t-e detection of any acti0ity by any means in any 1art of t-e brainBanyt-ing !ess t-an >w-o!e brain deat-?B1rec! des t-e diagnosis of deat-, and t-e remo0a! of t-e -eart from s c-

1atients wo !d be n!awf !& T-ere -a0e been many re1orts of 0ario s forms of resid a! e!ectrica! and ne ro-ormona! acti0ity in t-e brain of s b4ects w-o ot-erwise met t-e criteria of deat-& $any a t-ors -a0e arg ed t-at 1atients e<-ibiting t-ese feat res are not dead and t-at t-e conce1t of brain deat- is f!awed, and some -a0e ad0ocated a ret rn to t-e traditiona! cardio1 !monary criteria&4K3 Britain -as been s1ared m c- of t-is contro0ersy& 5n 2372 $o-andas and /-o c!aimed t-at damage to t-e brain stem was t-e cr cia! com1onent of se0ere brain damage ca sing 1rofo nd irre0ersib!e coma&20 5n 237" t-e 78 /onference of Roya! /o!!eges and t-eir (ac !ties acce1ted t-is and defined brain deat- as t-e com1!ete and irre0ersib!e !oss of f nction of t-e brain stem&22 T-ey disco nted t-e re!e0ance of resid a! acti0ity in t-e 11er brain) wit-o t f nction of t-e brain stem, !ife does not e<ist& 5n 1ractice t-is definition -as 1ro0ed rob st& (o!!ow 1 of a series of o0er 2300 1atients diagnosed as brain dead on t-e basis of !oss of brain stem f nction s-owed t-at cardio1 !monary deat- ens ed ra1id!y in a!! cases e0en w-en s 11orti0e treatment was maintained&2' :es1ite t-e s1ate of artic!es in t-e 7# 1ress e<1ressing dissatisfaction wit- t-eir w-o!e brain criteria, /a1ron -as 1ointed o t t-at t-e consens s abo t t-e determination of deat- -as end red t-ere for more t-an 30 years&3 T-e sim1!er and re!iab!e 78 definition -as not e0o=ed simi!ar criticism& T-at e0ening, a!most 34 years ago, w-en 5 stood at t-e bedside of my 1atient wondering w-at on eart- to do, t-ere were no g ide!ines for testing for t-e 1resence of brain deat-Bt-e conce1t -ad not yet been form !ated& Today, t-e recogniGed forma! 1roced re to estab!is- it wo !d -a0e made my decision a !ot easierBand 5 mig-t e0en -a0e -ad a 1ro1er nig-t6s s!ee1&