Guy Alexandre, Physician Who Redefined Death, Dies at 89

The physician who removed the organs of hundreds of his patients before they were declared dead died on February 14. Sixty years ago, Dr. Guy Alexandre was the first transplant surgeon to remove organs from a patient with a beating heart. His colleagues thought he was committing murder. Alexandre thought not.

His son Xavier Alexandre, who lives in Jerusalem, confirmed his death.

One of the biggest controversies in the Orthodox Jewish world in the 20^th century surrounded the concept of brain death. Did the death of the human brain mean the human being was dead even though the body’s heart was still beating? Dr. Alexandre was the first person in the medical field who asserted yes.

I went to visit Prof. Alexandre a few years ago to discuss his role in getting the medical establishment to accept brain death (aka Neurological Death) as death of the human being. Although Alexandre was charming and avuncular he did not mince words about his critics: “they were hypocrites. They viewed their heart-beating brain-dead patients as alive yet they had no qualms about turning off the ventilator to get the heart to stop beating before they removed the organs. Were they not murdering their patients?”

Brain death was not well-known in 1963. How did Belgium-based Alexandre get consent from families to donate the organs of their loved one? “We didn’t. After confirming that the patient was brain-dead, we removed the organs in the middle of the night and told the family the next morning their loved one had died overnight.”

In 1961, when Alexandre was in his 3^rd year of surgical training, he left Brussels for Boston to train at Harvard Medical School. He studied under Professor Joseph Murray, the surgeon famous for performing the first successful kidney transplant between twins in 1954. Alexandre was invited by Murray to join him in the operating room and it was there that Alexandre noticed a curious phenomenon.

Murray turned off the ventilator in order to cause the heart to stop beating and only then did he extract the kidneys. By doing this he was slightly damaging the kidneys by depriving them of oxygen. Alexandre felt there was no need to damage the organs because he believed he was looking at a corpse with a beating heart. In other words, the organism was dead but the organs were being kept alive with the help of a ventilator.

Upon finishing his graduate fellowship at Harvard two years later – armed with new surgical skills, new anti-rejection drugs, and a new perspective on death – Alexandre returned to Brussels. He worked at the Cliniques Universitaires Saint Pierre in Louvain under the aegis of Dr. J. Morelle, Chief of Surgery. Alexandre shared his thoughts about death with Morelle and they were of similar mind: brain death – albeit in the presence of a beating heart – is death of the human being.

Although not neurologists, Alexandre and Morelle decided upon 5 criterions to establish that the brain was dead. A patient on a ventilator who was unconscious and unresponsive as a result of a head trauma, if his pupils were dilated and fixed, had no reflexes or response to pain, no autonomous respiration, falling blood pressure and a flat EEG they considered the patient dead.  On June 3, 1963, Alexandre had such a patient.

Alexandre and Morelle told the family the situation was dire and when the family left the hospital they wheeled the body into the operating theatre and there – for the first time in modern medical history – organs were purposely removed from a human body that had a beating heart. Those first cuts of the scalpel not only destroyed the skin but also the conventional definition of death that had reigned for thousands of years: brain death plus cardiac arrest.

Morelle and Alexandre did not invent the concept of brain death. Brain death with a beating heart was fully described in the medical literature in 1959 by French Physicians Mollaret and Goulon who called it Comma Depasse, literally ‘beyond coma’. But they did not consider brain death to be human death; how could they in the presence of a beating human heart? But the question begs to be asked: What stopped them? Given the knowledge they had about the role the brain plays in making us human, what prevented men of medicine from jumping this conceptual chasm? Why did a beating human heart captivate them? Most likely there were multiple reasons.

First and foremost, physicians are sworn to the Hippocratic oath: not to harm their patients. It is simply counterintuitive for a physician to remove human organs thus causing the patient’s heart to stop beating. Emotionally it was difficult as well: a beating human heart inside a warm human body does not an appearance of a death make.

Culture also likely played a role. Society always viewed a beating human heart as a symbol of human life and as such the heart looms large in literature and lyrics, poetry and paintings. Symbols – unlike people – do not easily die. The night you tell your spouse you love her from the bottom of your brain is the night you are sleeping on the couch.

Human perception is also a culprit. A cadaver with a beating heart is warm to the touch and the person looks like he is sleeping. We can’t, with the naked eye, see inside the skull. If we could, our perception of this cadaver as a living human being would be shattered.  It would be akin to looking at a decapitated body whose heart continues to beat.

And let us not forget the bane of all human progress – inertia. For many millenniums the cardiac arrest criterion of death was the standard of death in all cultures. To suddenly ignore a beating heart as a sign of human life would be the ultimate paradigm shift – reframing the boundary between life and death.

Alexandre knew that a heart can beat in a bucket of saltwater and no one would confuse it with a human being. Similarly, he thought, if a heart beats inside a corpse, why would anyone view it as a living human being? A beating heart is necessary but not sufficient for human life in the same way an airplane engine is necessary but not sufficient to constitute an airplane. Ironically, the greatness of Alexandre’s insight was that he was able to see the insignificance of the beating heart.

But Alexandre’s charge that doctors were hypocrites for turning off a ventilator as they too were killing their patient might be a little too harsh. It is possible doctors viewed the patient as alive and they were simply removing an impediment – the ventilator – that was preventing the body from doing what it wanted to do: die. They didn’t believe they were causing the death of the heart; the trauma the body had previously underwent caused it to stop beating. Removing the ventilator, for them, was akin to a passive intervention. When asked about this Alexandre said he felt there was no difference between “actively killing” and “passively killing” a patient.

Alexandre had already removed organs from 9 heart-beating brain-dead cadavers when he presented his work at the CIBA conference in London in 1965, the first international conference on the ethics of transplantation. His colleagues were shocked.

Dr. Tom Starzl, the pioneer American liver transplant surgeon who was present at the conference, said that no member of his team would consider the patient “dead as long as there was a heartbeat.” Dr. Roy Calne said that Alexandre’s behavior will cause the field of organ donation “to fall into disrepute.” Professor Louisell warned that such behavior “could incur the danger of a possible charge of homicide.”

Alexandre held his ground and continued his work removing organs from more than 300 heart-beating cadavers without getting consent from next of kin. His new definition of death was vindicated 5 years later in 1968, when the Harvard Ad Hoc Committee concluded that brain death was death – even in the presence of a beating heart. They didn’t mention Alexandre.

What happened in that 5-year period from 1963 to 1968 that caused the scales to fall from the eyes of the medical community is not clear. Most likely it was the growing success of organ transplants due to new anti-rejection drugs and the accompanying growing need for transplantable undamaged organs. And perhaps the transplant successes of Dr. Guy Alexandre loomed large in their calculations.

Alexandre was even further vindicated when the committee determined the 5  criteria to establish brain death: they were identical to Alexandre’s. But vindication was bittersweet: nowhere was Alexandre’s name mentioned in their documentation or discussion when in fact it was Alexandre and Morelle who redefined death for all of humanity consequently and subsequently saving millions of lives by making organs available for transplant.

What about the charge of stealing organs? Alexandre defends himself: ‘‘In Belgium the coroner was allowed to perform an autopsy and remove and examine organs without permission from – and even over the objection of – the family (indeed, at that time this was also the law in France and England.) “So shouldn’t a surgeon be allowed to take an organ out of a dead body, similarly without the permission of the family in order to save another patient’s life? And to tell you the truth, I don’t ever remember if those doctors who turned off the ventilator first and then removed kidneys got permission from families either!”

Against this charge Alexandre was again vindicated in 1986 when Belgium legislation explicitly stated that physicians may remove organs for transplantation without asking permission from the family unless the donor had expressed opposition during his or her lifetime.

Impressively, redefining death was not Alexandre’s only significant medical contribution to the field of transplantation. Early on physicians discovered that people of different blood types could not share organs. However, in the early 1980s, Alexandre transplanted a kidney that had a mistakenly labeled blood-type.

When the mistake was discovered, Alexandre kept close watch on the recipient but no rejection occurred. Pleased, surprised, and curious, Alexandre pondered that perhaps ABO incompatible transplantation was not so incompatible.

He came up with the idea of using a known technique called plasmapheresis to clean a recipient’s blood stream from antibodies before the transplant. He then – for the first time in medical history – purposely transplanted a non-compatible donor to patient. He allowed a woman to donate her kidney to her daughter even though they had different blood types. The plasmapheresis worked and the transplanted kidney was received by the recipient with no rejection. This protocol was quickly adopted through the world.

Alexandre’s contribution to society by his paradigm shift concerning the definition of death saved millions of lives throughout the world by enabling organ donation of undamaged organs. Alexandre never received the recognition for his contribution during his life time. May this obituary serve as a correction to the historical record.

Guy Pierre Jean Alexandre was born July 4, 1934 and is survived by his daughters Anne, Chantal, Brigitte and Psacale and his son Xavier.