What does it mean for a human being to “die”? This question is more complex than one might think. In the domain of vital organ procurement, there is significant disagreement about the criteria that we should employ to assess when someone has died.
The standard criterion for several decades has been the “brain death” criterion, according to which a patient can be pronounced dead once “whole brain death” has occurred. Whole brain death refers to the comprehensive and irreversible cessation of brain function, typically caused by trauma, anoxia or tumor.
Yet transplant surgeons have in recent years employed a different, more ethically contentious definition of death, the so-called “circulatory criterion for death”. “Circulatory death” refers to the permanent cessation of cardiopulmonary function, after which point brain tissue quickly begins to deteriorate (if it hasn’t already).
According to proponents of the circulatory criterion, a patient’s heart will never spontaneously restart after 2 or so minutes of pulselessness. As such, it is seen as ethically permissible to begin organ procurement once this short time period has elapsed. There are in practice different time periods specified by healthcare regulators for when organ procurement can begin (typically between 75 seconds and 5 minutes).
Yet several scholars have criticised the cardiopulmonary definition of death, arguing that the impossibility of autoresuscitation does not necessarily indicate that death has occurred. Critics point out that CPR could still restart a person’s heart even when autoresuscitation has become an impossibility.
The most recent criticism came from Kennedy Institute for Ethics bioethicist Robert Veatch, who wrote an extended blog post on the topic this week. Veatch states:
If one opts for requiring physiological irreversibility, death should be pronounced whenever it is physiologically impossible to restore brain function. Autoresuscitation is completely irrelevant. If autoresuscitation can be ruled out before physiological irreversibility, one must still wait until that point is reached. On the other hand, if it becomes physiologically impossible to restore function before autoresuscitation can be ruled out, death can be pronounced at the earlier point. Either way autoresuscitation is irrelevant.
This article is published by Xavier Symons and BioEdge under a Creative Commons licence. You may republish it or translate it free of charge with attribution for non-commercial purposes following these guidelines. If you teach at a university we ask that your department make a donation to BioEdge. Commercial media must contact BioEdge for permission and fees.
A team of doctors affiliated with the University of Western Ontario in Canada has documented a case in which a terminal patient removed from life support continued to experience brain wave activity for approximately 10 minutes after they had been pronounced clinically dead. In their paper published in The Canadian Journal of Neurological Sciences, the team describes the circumstances of the unusual event and acknowledge that they have no explanation for what they observed.
For many years, doctors have used a handful of tools to determine if someone has died—a lack of pupil dilation, heart stoppage, lack of breathing, etc. But one test has stood above all others—an EEG reading. Even if the heart is beating and a person is breathing, if the brain stops processing electrical signals, that person is considered clinically dead—though in some cases they may be labeled as brain dead. But what if a person’s heart stops beating, meaning there is no blood flow to the brain, and the brain continues to show delta wave bursts for up to ten minutes? Prior to this event occurring in Canada, it was thought to be an impossibility. . . [Full text]
The academic conversation over brain death continues, with the American journal of Bioethics publishing a special issue on the status of death determined by neurological criteria (DDNC).
The issue contains 20 articles offering different perspectives brain death. Most of the papers refer a recent legal battle in Texas over Marlise Munoz, a brain dead woman carrying a second trimester foetus.
The papers are highly technical and difficult to summarize in a short post. There are, however, a number of clear themes:
– The academics argue over the philosophical definition of death: is it the cessation of mental processes, the end of what is know as the ‘organism as a whole’, or the end of functions such as respiration, metabolism, and growth?
– They consider whether it is problematic to have a legal definition of death distinct from a ‘real’ (i.e. philosophically justifiable) conception of death.
– They discuss the need for educating medical practitioners and the general public about the legal definition of brain death.
Bioethicist Thaddeus M. Pope says the issue is particularly timely as we may see a number of legislative debates about brain death in the near future.
This article is published by Xavier Symons and BioEdge.org under a Creative Commons licence. You may republish it or translate it free of charge with attribution for non-commercial purposes following these guidelines. If you teach at a university we ask that your department make a donation to Bioedge. Commercial media must contact Bioedge for permission and fees. Some articles on the Bioedge site are published under different terms.
The American Journal of Bioethics, 14:8, 3-8, (2014) DOI:10.1080/15265161.2014.925153
James L. Bernat
The publicity surrounding the recent McMath and Muñoz cases has rekindled public interest in brain death: the familiar term for human death determination by showing the irreversible cessation of clinical brain functions. The concept of brain death was developed decades ago to permit withdrawal of therapy in hopeless cases and to permit organ donation. It has become widely established medical practice, and laws permit it in all U.S. jurisdictions. Brain death has a biophilosophical justification as a standard for determining human death but remains poorly understood by the public and by health professionals. The current controversies over brain death are largely restricted to the academy, but some practitioners express ambivalence over whether brain death is equivalent to human death. Brain death remains an accepted and sound concept, but more work is necessary to establish its biophilosophical justification and to educate health professionals and the public. [Full text]
The American Journal of Bioethics, 14:8, 9-14 (2014) DOI: 10:1080/15265161.2014.925154
Robert D. Truog, Franklin G. Miller
- We seek to change the conversation about brain death by highlighting the distinction between brain death as a biological concept versus brain death as a legal status. The fact that brain death does not cohere with any biologically plausible definition of death has been known for decades. Nevertheless, this fact has not threatened the acceptance of brain death as a legal status that permits individuals to be treated as if they are dead. The similarities between “legally dead” and “legally blind” demonstrate how we may legitimately choose bright-line legal definitions that do not cohere with biological reality. Not only does this distinction bring conceptual coherence to the conversation about brain death, but it has practical implications as well. Once brain death is recognized as a social construction not grounded in biological reality, we create the possibility of changing the social construction in ways that may better serve both organ donors and recipients alike.[Full text]
Croat Med J. 2013 Feb;54(1):75-7. PubMed PMID: 23444250; PubMed Central PMCID: PMC3583397
Brain death or neurologic death has gradually become recognized as human death over the past decades worldwide. Nevertheless, in Japan, the New York State, and the State of New Jersey, one can be exempt from death determination based on neurologic criteria even in the state of brain death. In Japan, the 1997 Act on Organ Transplantation legalized brain death determination exclusively when organs were to be procured from brain-dead patients. Even after the 2009 revision, the default definition of death continued to be cardio-pulmonary criteria, despite the criticism.
The cases of Japan and the United States provide a good reference as social experiments of appreciating conscientious or religio-cultural dimensions in health care. This text theoretically examines the 1997 Act on Organ Transplantation of Japan and its 2009 revision, presenting some characteristics of Japan’s case compared to American cases and the implications its approach has for the rest of the world. This is an example in which a foreign idea that did not receive widespread support from Japanese citizens was transformed to fit the religio-cultural landscape.
Brain death (neurologic death) has gradually been recognized as human death over the past decades worldwide. Nevertheless, in Japan, the New York State, and the State of New Jersey, one can be exempt from death determination based on neurologic criteria even in the case of brain death. The New York State established the Guidelines for the Determination of Brain Death (1987, 1995, 2005) to accommodate religious or moral objections to brain death. The State of New Jersey also enacted the Declaration of Death Act (1991) to accommodate religious objections to brain death. All this resulted from the accommodation of religious and moral objections to neurologic criteria.
Hans-Martin Sass argued for “a formula for a global Uniform Determination of Death statute, based on the ‘entire brain including brain stem’ criteria as a default position, but allowing competent adults by means of advance directives to choose other criteria for determining death during the process of dying.” These cases provide a good reference as social experiments in order to evaluate this formula.
In the text, the term “conscience” or its adjective form is chosen as a superordinate concept to moral/religious belief according to conventional usage. Conscience might appear universal whereas religio-cultural dimension differs among nations. In this text, conscience is considered to manifest itself within different societal traditions.[Full Text]
A 19 year old girl who was seriously injured in a car crash in October, 2011, narrowly escaped having vital organs removed for transplant following what appears to have been a misdiagnosis by attending physicians. After consulting with the family, they removed a respirator and ceased treatment. However, the girl regained consciousness as they were preparing to harvest her organs. [Medical Daily]