Brain Death

While the term "brain death" has been around since 1968, there is no common international agreement of the neurological criterion.

  • The traditional definition of death was 'someone who irreversibly is no longer breathing, has no circulation, and whose heart is no longer beating is dead.'
  • The idea of "brain death" was devised to be able to avoid controversy in harvesting useful organs.
  • The Harvard 'criteria' were published without substantiating data from either scientific research or from case studies of individual patients.
  • When the criteria based on the Collaborative Study became the practice and a standard for determining brain death, 96% of the patients did not and do not have a dying brain stem.
  • Some people who have been given a diagnosis of "brain death" have woken up and recovered.
  • In a person declared "brain dead," the brain is still functioning to control temperature, blood pressure, cardiac rate and salt and water balance.
"Brain death" is defined as the "irreversible cessation of all functions of the entire brain, including the brain stem."

Just as there is disagreement as to when life actually begins, bioethicists and medical professionals also disagree over the exact definition of death.

The definition of death that was traditionally accepted until the second half of the twentieth century was someone who irreversibly is no longer breathing, has no circulation, and whose heart is no longer beating is dead.

In New Zealand, according to the Australian and New Zealand Intensive Care Society (ANZICS),there is no statutory definition of death.

In 1968 however, the idea of "brain death" was devised by a Harvard Medical School Ad Hoc Committee to Examine the Definition of Death. Henry Beecher, the physician who chaired the ad hoc Committee said,

"Can society afford to discard the tissues and organs of the hopelessly unconscious patient when he could be used to restore the otherwise hopelessly ill, but still salvageable individual?" 1

He went on to say, "It is best to choose a level where although the brain is dead, usefulness of other organs is still present." 2

One of the two reasons the Harvard Committee gave for formulating the brain death criteria was that the traditional definition of death is "obsolete" and "can lead to controversy in obtaining organs for transplantation.3

The Harvard 'criteria' were published in the Journal of the American Medical Association under the title of "A Definition of Irreversible Coma," without substantiating data from either scientific research or from case studies of individual patients.

It was that lack of data that caused disagreement among bioethicists and medical professionals.

Certification of brain death
The ANZICS says that certification is not complete until the two separate clinical examinations have been performed.

The first formal examination should only be performed after:
  • all the preconditions have been met
  • a minimum of four hours observation and mechanical ventilation during which the patient has been comatose (Glasgow coma score 3), had non-reacting pupils, absent cough and gag reflexes, and no spontaneous breathing efforts
These observations of lack of function should have been recorded by attending nursing or medical staff. The second examination should not be performed until at least two hours after the first examination.4

See The Brain Death Test

No consensus
In 2002 the results of a worldwide survey were published in Neurology, concluding that the use of the term "brain death" worldwide is "an accepted fact but there was no global consensus on the diagnostic criteria" and there are still "unresolved issues worldwide".

To add to the confusion, in just one decade, between 1968 and 1978, at least 30 differing sets of criteria were published, and there have been many more since then.

Every time a new set of criteria is produced it tends to be more open to interpretation and less rigid than earlier sets. Critics have pointed out that none of them is based on the scientific method of observation and hypothesis followed by verification.

Dr. Paul Byrne, president of the Catholic Medical Association, in an address at the Third International Congress of the Movement for Life convened by the Pontifical Council for the Family on October 4, 1995 said:

"...even though the Uniform Determination of Death Act calls for "... irreversible cessation of all functions of the entire brain, including the brain stem," this is not what is occurring in practice. The Annals of the New York Academy of Science (ANYAS 9, 315, pg. 65, 1978) reported that only 4 percent of the patients in the Collaborative Study would have met the criteria of a dying brain stem.

To say it another way, when the criteria based on the Collaborative Study became the practice and a standard for determining brain death, 96% of the patients did not and do not have a dying brain stem. While this is only one set of criteria, whether it or any other set of criteria based on the Collaborative Study is used, 96 percent of the so-called "brain-dead" patients still have a functioning brain.

When the beating heart is then excised [cut out], the patient becomes dead, i.e., the patient is killed.

The acceptance of brain death is a major link in the euthanasia movement. Many of the difficult issues of euthanasia have been evaded by the acceptance of brain death (Willard Gaylin).

"Brain death" is not death. Brain death is not based on data that would be considered valid for any other scientific purpose."
5

Organ harvesting
In 1974, Willard Gaylin, M.D., a psychiatrist who was, at the time, president of the Institute of Society, Ethics and the Life Sciences in Hasting-on-Hudson, New York, wrote an article for Harper's Magazine entitled "Harvesting The Dead."

In the article, Gaylin came up with a new term, "neomort" to cover someone who was legally dead yet retaining the qualities of a living person, i.e.: warm, respirating, pulsating, evacuating, and excreting body requiring nursing, dietary, and general grooming attention.

Gaylin proposed that these "neomorts" could then be stored in "neomortoria" (units in hospitals where neomorts on life-support systems could be housed) for organ transplantation, medical and nursing education, and drug research.

A number of physicians are uncomfortable with a diagnosis of "brain death" because the patients do not "look dead." "Brain dead" patients, aided by a ventilator (which supports but doesn't breathe for a patient) have beating hearts, healthy skin color, warmth, digestion, and metabolism. They have even , on life support, continued to nourish a child in the event of pregnancy until a caesarian birth can be safely performed.

The objection most frequently raised however, against harvesting the organs of those diagnosed as "brain dead," is that current criteria for determining brain death cannot adequately assess the presence or absence of irreversible coma.

To put it another way, some people who have been given a diagnosis of "brain death" have woken up and recovered.

In some cases, too many medications or the wrong medications can play a role.

Dr. Kester Nedd, head of neurological rehabilitation at the University of Miami School of Medicine.

"If you really investigate the case, a lot of times it's either a progressive improvement that was ongoing or there's been something like an infection that literally suppressed the person's activity.

"I've had patients come to me seemingly in a coma and are on too much medication or on drugs with interactions that affect portions of the brain that limit the brain, by modifying their medication or putting them on drugs that are more stimulating, I could seemingly cause dramatic recovery. This is not an infrequent occurrence.

Some patients may have low-level seizures that are undetectable on an ordinary EKG. When that area of the brain is treated, the patient appears to wake up."
Paul Sanberg is a distinguished professor of neurosurgery and director of the University of South Florida Center for Aging and Brain Repair in Tampa. He said,
"We now know that the brain has endogenous stem cells that continue to grow and develop. And while the endogenous stem cells aren't enough to repair traumatic events by themselves, they can repair smaller events, or over many, many years they may repair enough to get an area functional again."
Read more on Organ Harvesting

Coma and brain death recoveries
Dr. Paul Byrne, who is also a Clinical Professor of Pediatrics, often refers to cases in which those who had met the criteria for brain death had recovered.

One of those cases he described like this:
"Who knows Joseph Van Dyke? I do. And so do his relatives and friends.

Joseph weighed 1 lb. 11 oz. when he was born. Six weeks after he was delivered, Joseph was still on a ventilator, unable to breathe on his own. An EEG was interpreted as 'consistent with cerebral death.' It was suggested that the ventilator be removed. However, we didn't do that. Instead, we continued the ventilator.

Today, he has finished the second grade, reads at the fourth grade level, and recently told me that he's playing baseball?but having difficulty with his hitting." Read more Coma Recovery Case Studies

While it is commonly believed that a "brain death" diagnosis means a patient will never improve or recover, it is acknowledged that because of the discrepancies between the different criteria for brain death, there is not only room for error, but it is difficult to make a correct diagnosis.

It is for this reason that critics say "brain dead" people are not dead, but dying.

The only thing bioethicists and medical professionals all seem to agree on is that there is no single neurological criterion that is commonly held by the international scientific community to determine death.

While some functions of the brain maybe either permanently or temporarily inactive, it is important to note that although a person on a ventilator may be declared "brain dead," the brain is still functioning to control temperature, blood pressure, cardiac rate and salt and water balance.

References:
  1. Contemporary Issues In Bioethics, 1982, pages 288-293
  2. Ibid
  3. Ibid
  4. www.anzics.com.au
  5. Paul A. Bryne, M.D. "Brain Death"-Beyond the Slogan