A Beating Heart in a Warm Corpse

Arnold Tweed

“A beating heart in a warm corpse.” This was how I described Donald George Junor when, on 26th July, 1975, he was taken to an operating room of the Winnipeg General Hospital to remove his kidneys for transplantation into another patient. This, of course, was not the diagnosis recorded in his medical chart but an afterthought, evidence given several months later at the trial of Louis George Adams and Clifford James Kitching for manslaughter in causing his death.  The official diagnosis on his chart was “traumatic brain injury with irreversible coma.” Irreversible coma was a relatively new concept developed specifically to identify suitable organ donors. We shall see later that this was a concept that challenged the conventional wisdom of the time and was difficult to defend.

On reading the newspaper reports one might simply dismiss this as a casual and flippant remark meant to call attention to the gravity of his injuries. That was certainly not the case. At that point in the trial I was struggling with a penetrating cross-examination by two very able defense lawyers, Robert Tapper and Greg Brodsky, who contended that it had been the doctors, not their clients, who had killed Donald Junor and the motive was to harvest his kidneys. I was the chief medical witness and I was forced to defend our actions in terms understandable to the court and to the public. This was an unrehearsed response to a simple but fundamental question by Mr. Brodsky; “Was Cpl. Junor alive or dead when you removed his kidneys?”

My response was meant to persuade a sceptical jury that his assailants had caused his death. And the members of the jury had good reason to be skeptical. The common understanding at that time was that a beating heart was the cardinal sign of life, and life ceased when the heart ceased to beat. I assumed that the jurors shared this view. My task was to convince them that the life and identity of Cpl Junor resided in his brain and ceased when his brain permanently ceased to function. More generally I was arguing that the ‘vital principle’ of life resided in the brain, not the heart.

The attached article by Anne Marie Travers, published in the Winnipeg Tribune, tells the story as seen by the press and public. On re-reading this article I cringe at the casual tone of my language. What a callous and off-handed way to describe another human being! There had to be justification to use such dismissive language, especially when the individual was a patient whose life was my trust. Now, forty years later, I would like to tell the story as I saw it, the story of Corporal Donald George Junor, who never sought this publicity.

Donald Junor was a 26-year-old soldier, home on leave in the midsummer of 1975. On the night of July 24 he was drinking alone in a bar in the Garment District of Winnipeg. He was not only drinking alone but drank to the point of unconsciousness. We know little about his personal life, or why he ended it in those sordid circumstances. He was not a derelict; he was a serving soldier, a Corporal in the PPCLI regiment then stationed in Esquimalt, BC.

Cpl. Junor passed out about midnight in the Vibrations Discotheque of the St. Charles Hotel after drinking for several hours. The hotel in its Edwardian grandeur still stands proudly at the corner of Notre Dame and Albert Streets. The two bouncers, who were subsequently charged with manslaughter, in an astounding act of callous bravado, lifted him by the armpits, dragged him up the stairs and dropped him face down on the sidewalk of Albert St. An taxi driver idling at the curb testified that it sounded like an egg hitting the concrete. Of course a conscious person would have reflexively lifted his head and taken the impact with his chest and arms. Cpl. Junor had no protective reflexes; his head hit the concrete as a dead weight dropped from a height of four feet.

On arrival at the hospital two things were quickly established. First he was drunk, with a blood alcohol level three times what was then considered too drunk to drive. Secondly he had a massive traumatic brain injury with rapidly progressive brain swelling and hemorrhage. Within hours it was apparent that his brain damage was lethal.

When we took Cpl. Junor to the operating room two days later to harvest his kidneys he was not officially dead. According to the criteria and terminology used then, known as the Harvard Criteria, he was in a state of ‘Irreversible Coma.’ The time of clinical death, when I signed his death certificate, was after his kidneys had been removed, after we had stopped the ventilator which breathed for him and after his heart had stopped beating.

It was the ambiguity between irreversible coma and clinical death that caused me much discomfort at the trial of his assailants. In justifying our actions I had to make two arguments that would be understood by the jurors: first that dying was a process, not an event, and second that irreversible coma marked a stage in the process where there was no possibility of recovery. The defense used the same clinical facts to argue that Cpl. Junor was alive when his kidneys were removed and stopping the ventilator was the proximal cause of death. We were the immediate agents of his demise, not their clients.

Living and dying are the Siamese twins of our existence, firmly locked together from conception and indivisible. After several millennia of careful observation you would think that we would have no difficulty in distinguishing one from the other. But, like Siamese twins, they may have certain resemblances and occasionally one may mimic the other. For example deep hypothermia can make the living appear dead and modern intensive care can make the dead appear to be alive. Many of our ancestors had a morbid anxiety about the possibility of a premature diagnosis of death. They were afraid that the appearance of death might be an illusion and were reluctant to abandon the hope for spontaneous revival. It was a custom in some parts of 16th Century England to hang a small bell over new graves with a cord down to the coffin, so that the not quite dead, awakening in the claustrophobic confines of the grave, could signal for help.

This uncertainty about the boundaries between life and death is founded in philosophical and theological constructs, belief in a ‘vital principle’ of life — or life force — which is distinct from the physical soma of the individual. This was the common belief in earlier times and still prevalent today. Western society generally followed the Catholic doctrine that the ‘vital principle’ or soul entered the body at conception and left at death, but there was no clear agreement where it resided in the body and at what point in the dying process it left. Probably the most common belief was that it resided in the heart and left when the heart ceased to beat. This was supported by the medical observations of the time that, after decapitation or hanging, the heart continued to beat for several minutes after all other vital functions had ceased. The beating heart as both the symbol and embodiment of life is thus firmly ingrained in western culture. Although clinical examination has always been the method by which death is confirmed, the diagnosis of alive or dead has never been a purely medical construct. Definitions couched in purely medical terms may suffice for practical purposes but do not address the mysteries of life and death.

When we accept that the ‘vital principle’ of life persists in a beating heart, it cautions us to be wary in the certification of death. Clinical examination must confirm that all signs of life are extinguished: breathing, heartbeat and reflexes. Since all physicians are aware that heartbeat may persist for some time after other vital functions have ceased, prudence urges one to be slow and methodical. Haste may punish the unwary. An unexpected agonal reflex jerk or terminal gasp can raise doubts in the minds of the superstitious and possibly cause acute embarrassment for the doctor.

Two advances in medical science — life-support intensive care and organ transplantation — forced the medical profession to re-examine the traditional approach. The historical criteria for determination of time of clinical death, complete absence of any signs of life, became an obstacle to medical progress in these fields.

Life-support intensive care, which owes its origins to poliomyelitis and the ‘iron lung’, changed our understanding of the dying process. The worst polio cases have ascending muscle paralysis affecting even their respiratory muscles; before intensive care those with respiratory paralysis usually died. The ‘Iron Lung,’ or Drinker negative pressure respirator, was first used at the Boston Children’s Hospital in 1928 and the Hospital for Sick Children in Toronto in 1937. It rescued many who would otherwise have died. In Manitoba these machines were introduced in the Municipal Hospitals during the polio epidemic of 1953, the worst of several dreaded epidemics of ‘infantile paralysis’.

The iron lung, though a brutally cumbersome machine, inaugurated a new era in medical care and a eureka moment in conceptual thinking about living and dying. Cessation of one of the vital functions, breathing, was no longer a certain harbinger of death. Modern intensive care can now substitute or support many vital functions: breathing, circulation and kidney function. Hearts that have arrested can be restarted and patients with lethal head injury and strokes can be kept ‘alive’ in classical terms for days or even weeks. But as yet we have no substitute for the functions of the human brain.

The first truly successful kidney transplant — successful in terms of long term survival, that is — was performed at the Brigham Hospital in Boston in 1954 by Dr. Joseph Murray (1919-2012). He received the Nobel Prize for Medicine in 1990 for his contributions to organ transplantation. It was successful mainly because the donor was a living identical twin. This circumvented the two major complications that cause a transplanted kidney to fail: immune rejection and ischemic injury prior to harvesting. In a very few years rejection would be better managed by tissue typing and immune-suppressant drugs. With rejection under control the supply of viable donor kidneys became the major limiting factor. Identical twins are the ideal donors but in short supply. Living-related donors are next best and still provide a significant proportion of all transplants. Genetically related donors are easier to match but the commercial trade in ‘kidneys for sale’ is fraught with hazards. At one time cadaver kidneys were used, but often they had been ischemic for too long and didn’t function.

The largest and most reliable pool has always been beating-heart donors. This pool is mainly populated by young people with lethal head injuries and we credit the motorcycle as our most consistent supplier. Because potential donors are mainly young and vulnerable there must be certainty in the diagnosis, not only to protect the donors but also to maintain the credibility of the whole transplant program. The limiting concern was not the technical procedures or protocols, it was a need for uniform and reliable criteria for certifying donors. Renal transplantation was technically successful and of proven benefit but, in order to both identify and protect potential donors, a new concept of death and dying was needed.

The first breakthrough came from the Harvard Medical School, the cradle of transplant surgery. In 1968 The Harvard Ad Hoc Committee on Brain Death published their diagnostic criteria for a ‘permanently non-functioning brain,’ in other words for total and irreversible arrest of all brain functions. These criteria were based on neurological examination, tests for apnea (absence of spontaneous breathing), absence of cranial nerve reflexes and flat EEG (brain electrical activity). However, although their mandate was to study brain death, they chose to call this state ‘irreversible coma’ implying that the state of functional impairment was both total and irreversible. It was their criteria we were using in July of 1975.

At that time this was a new concept for doctors, lawyers and certainly the public. We recognized clinical death (permanent cessation of all vital functions) and biologic death (decomposition) but where did this new idea fit? Coma was familiar but how could we be certain it was irreversible?

At the trial it was therefore necessary to convince the jury that dying is a process and not an event. ‘Irreversible coma’ is a step in that process and without life-support all other vital functions will soon fail. Life-support can artificially maintain breathing and circulation for some time, but not indefinitely. Clinical death, as defined by traditional concepts, was inevitable but there was a short window of opportunity during which some vital organs were still healthy and could be harvested for transplantation.

This was an important conceptual shift but left a lingering uncertainty. The solution came by a simple analogy with traditional thinking about clinical death. If permanent cessation of heartbeat is accepted as cardiac death then permanent cessation of brain function must be ‘brain death,’ and both are precursors to biological death of all other tissues and organs. In both cases the ‘life principle’ has abandoned the body. Both allow a window of opportunity, longer with brain death, during which healthy organs can be harvested for transplantation.

The Manitoba legislature, in its Vital Statistics Act of 1975, provided the first statutory definition of death in Canada: “the death of a person takes place at the time at which irreversible cessation of all that person’s brain function occurs.” In 1981 the Law Reform Commission of Canada recommended that Parliament enact this provision in the Interpretation Act.

Agreement on the procedures for determining ‘brain death’ is coming together, and several expert committees have published virtually identical criteria. These often include ancillary tests, cerebral angiography or radio nucleotide scanning, which measure intracranial blood flow. When the brain is lethally damaged by trauma, stroke or tumor it swells; and this swelling increases the pressure inside the skull, which is a closed space. When the ICP (intracranial pressure) is equal to the systolic blood pressure circulation of oxygenated blood to the brain ceases. These techniques can accurately confirm complete absence of perfusion of brain tissue at all levels. An organ with no blood flow is a dead organ and will soon enter the biologic (disintegration) stage of dying. ‘Brain death’ is now generally accepted as equivalent to death of the person, although all other major organs may remain alive and functional for some time.

Modern medical science has resolved the age-old debate. We have established that the centre of identity, of conscious awareness, of everything that makes us individual lies in the brain, not in the heart. In spiritual terms you might also say we have located the ‘vital principle’ of life (the soul if you choose to think of it in those terms) in the brain. All other organs of the body are ancillary and replaceable.

When I discovered the newspaper clipping in my files and began to think about this story I searched for a closure that would adequately express our debt to Cpl. Junor. By coincidence he and I had played our parts in a significant period of medical history, though his participation was not by choice. It is often only in retrospect that we recognize we have been part of a social transformation. Major medical innovations all follow a similar pattern: technical expertise is usually achieved first. Professional and public acceptance follows at a much slower pace. Acceptance of new medical interventions often requires revision of established social attitudes and values. This was the case for both intensive care and organ transplantation. Neither could achieve their full potential until social attitudes towards living and dying had changed. The same can now be said for therapeutic abortion and now for MAiD (Medical Assistance in Dying). I am gratified and humbled to have played a role in that process. However, even though their sacrifice was so much greater, the contributions by Donald Junor and others like him often go unrecognized.

Before I could submit his story to public scrutiny I needed to reconnect with Cpl. Junor. I needed to recapture some of the ambience associated with these events and to test the authenticity of my memories. I also wanted to see what visible legacy history had assigned him. His burial site was easy to find on an internet registry. My wife and I visited his grave on a warm August afternoon in 2016, a little more than 41 years after the events I have described.

The municipal cemetery of Estevan, Saskatchewan is located on a gently sloping hillside at the north edge of the city. Cpl. Junor is buried in the military section, near the top of the slope. Nearby in this section lies another military Junor: LCpl. Hugh Dennis Junor (1903-1962). This location is prime cemetery real estate with good Fung Shui, pleasant view, soothing breezes and gentle drainage. The gravestone (see photo below) is inscribed in simple military format: regimental number, rank, name and dates. It will be visible long after the other details of this episode have faded from memory.

 

 

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Grave of Cpl Donald George Junor, age 26.
City of Estevan cemetery, Estevan, Saskatchewan.

 

No soldier chooses to die in the service of his country, but many do. No soldier can choose the time, place and circumstances of his dying. These are not considered relevant when we honor a dead soldier; we believe that all who die in the service of their country deserve equal respect. Donald Junor did not choose to be killed in a sordid midnight tragedy outside a sleazy nightclub, but in his dying he served his countrymen in a manner he could never have anticipated. His legacy, for those who care to inquire, is inscribed on his gravestone. Donald George Junor was a soldier; he is buried in a soldier’s grave and this story is a tribute to his memory.

 

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Winnipeg Tribune article, 1976

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Author: Arnold Tweed

Retired anesthesiologist living in Toronto, Canada.