In early June 1963, a patient with massive head trauma was rushed to a hospital in Belgium after a car crash. Surgery was performed. Yet the injuries were so severe that doctors declared the patient “brain-dead” – fully unresponsive but with a still-beating heart.

In another ward of the hospital, a patient was struggling with kidney failure and was in urgent need of a transplant.

A doctor just back from a fellowship in Boston, Guy Alexandre, went to the hospital’s head of surgery with an unprecedented request. Take the kidneys from the crash victim while the patient’s heart was still functioning, he appealed. This would reduce the biological breakdown that occurs in organs after even a few minutes without oxygen.

The chief of surgery, Jean Morelle, made “the most important decision of his career” and approved the procedure, said Dr. Alexandre, who died Feb. 14 at his home in Brussels at 89.

The transplant, performed on June 3, 1963, would eventually usher in a transformation in medical ethics, challenging perceptions of death and testing the boundaries of a fundamental principle of medicine, “do no harm.”

But first, he faced a torrent of questions and recriminations that put his reputation and career on the line. He stood firm. He noted that the patient who received the transplanted kidney lived another 87 days, which was considered a significant outcome at a time when transplant science was still developing.

He also described the physicians who accused him of murder as hypocrites. “They viewed their brain-dead patients as alive,” he said in a 2019 interview with Tablet magazine, “yet they had no qualms about turning off the ventilator to get the heart to stop beating before they removed kidneys.”

In the end, his views prevailed. By the late 1960s, he had the support of influential medical societies. Today, doctors are considered within ethical grounds to remove transplant organs from patients who display his five-point criteria for determining what he called “brain death.” They include no reflexes or responses to pain, a flat electroencephalogram (EEG) and the inability for autonomous breathing.

When he was given the approval for the first “brain-dead” transplant in 1963, the hospital did not contact the patient’s family for permission. “If you would have asked that, we would have [been] refused,” he said in a 2018 interview. He justified the decision by saying it was “self-evident” that the patient had no chance of recovering.

‘‘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,” he once said. “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?”

The family of the donor was told the patient died during the night. He performed eight other similar transplant procedures over the next two years. In 1965, he was invited to London for a medical conference on transplant ethics. He embraced the role of lead provocateur.

He asked why a heartbeat was considered the only definition of life, asserting that brain activity is an equally relevant measure. He told the conference that he was “taking organs from a dead person,” holding the same ethical standard as any other physician. He used the phrase “heart-beating cadaver.”

Some doctors at the conference were aghast and raised scenarios such as cases of barbiturate overdose in which a patient had a flat EEG but then recovered. He countered that the EEG was just one of the five metrics he used to declare a patient “brain-dead.” He left London appearing to have swayed some doctors and hospital administrators to consider his side, but critics remained.

Thomas Starzl, an American transplant surgeon at the conference, vowed that no member of his team would consider a patient “dead as long as there was a heartbeat.” Near the end of the gathering, attendees were asked to show who backed Dr. Alexandre’s definition of “brain death.”

“I was the only one to raise my hand,” he recalled. “All the others did not.”

Still, Dr. Alexandre helped stir debate on a “new approach to the definition of death,” Calixto Machado, a Cuban researcher in neurosurgery, wrote in the July 2005 issue of the journal Neurology.

In December 1967, South African surgeon Christiaan Barnard performed the first heart transplant from a donor who had been declared “brain-dead.” The next year, the concept of using neurological criteria to determine death was supported by the Harvard Ad Hoc Committee and the World Medical Assembly.

Nobel mentor

Guy Pierre Jean Alexandre was born on July 4, 1934, in the Brussels suburb of Uccle. His father worked in government administration, and his mother was an executive assistant.

Dr. Alexandre completed his medical studies in 1959 at the University of Louvain, where he received additional training as a transplant surgeon. In 1961, he was granted a Harvard University fellowship and studied state-of-the-art transplant procedures at Peter Bent Brigham Hospital (now part of Brigham and Women’s Hospital), one of Harvard’s teaching hospitals and where the first kidney transplant took place in 1954.

He worked under Joseph E. Murray, who shared the 1990 Nobel Prize in physiology or medicine for advances in transplant surgery. During one kidney transplant by Murray, he was invited into the operating room. He noticed that the donor’s kidney was slightly damaged by the lack of oxygen after the respirator was turned off, waiting for the patient’s heart to stop.

Already, he was familiar with the concept of coma dépassé, literally “beyond coma,” which had been used by francophone doctors since the late 1950s.

“[The doctors in Boston] viewed their 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 kidneys,” he recounted. “In addition to ‘killing’ the patient, they were giving the recipients damaged kidneys.”

He returned to Belgium in 1963 to become a professor at the University of Louvain and a transplant specialist at associated hospitals. During the 1980s, he developed techniques to help allow transplants between people with incompatible blood types, and performed one of the first successful interspecies transplants, known as xenotransplants, placing a pig kidney in a baboon.

His wife of 65 years, Eliane Moens, died in October. Survivors include five children; 17 grandchildren; and 13 great-grandchildren. His son Xavier Alexandre confirmed the death but did not note a cause.

He was once asked whether he thought the early resistance to his ideas was ingrained by art and culture, which long described the heart as the home of emotion and feeling. He looked to his Catholic faith and his belief in a soul that lives on.

“We know that we are dust,” he said. “And you take organs from a patient, from a corpse, so you take a little bit of that dust.”

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