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Why the Concept of Death is Valid as a Definition of Brain Death
Statement by the Pontifical Academy of Sciences
The Notion of Brain Death
The notion of ‘brain death’ was introduced to refer to a new criterion for the ascertainment of death (able to go beyond the criteria relating to the heart and breathing and the criteria relating to the destruction of the soma) that had become evident with new discoveries about the working of the brain and its role within the body, as well as necessary with the changed clinical situations brought about by the use of the ventilator and the possibility of sustaining human organs despite the loss of the unity of the organism as a whole.
Brain Death is Death
Brain death has been a highly important and useful concept for clinical medicine, but it continues to meet with resistance in certain circles. The reasons for this resistance pose questions for edical neurologists, who are perhaps in the best position to clarify the pitfalls of this controversial issue. To achieve consistency, an important initial clarification is that brain death is not a synonym for death, does not imply death, or is not equal to death, but ‘is’ death.
‘Coma’, the ‘Persistent Vegetative State’, and the ‘Minimally Conscious State’ are not Brain Death
The inclusion of the term ‘death’ in brain death may constitute a central problem, but the neurological community (with a few exceptions) acknowledges that something essential distinguishes brain death from all other types of severe brain dysfunction that encompass alterations of consciousness (for example, coma, vegetative state, and minimally conscious state). If the criteria for brain death are not met, the barrier between life and death is not crossed, no matter how severe and irreversible a brain injury may be.
Brain Death is the Death of the Individual
The concept of brain death does not seek to promote the notion that there is more than one form of death. Rather, this specific terminology relates to a particular state, within a sequence of events, that constitutes the death of an individual. Thus brain death means the irreversible cessation of all the vital activity of the brain (the cerebral hemispheres and the brain stem). This involves an irreversible loss of function of the brain cells and their total, or near total, destruction. The brain is dead and the functioning of the other organs is maintained directly and indirectly by artificial means. This state results solely and specifically from the use of modern medical techniques and, with only rare exceptions, it can only be maintained for a limited time. Technology can preserve the organs of a dead person (one appropriately pronounced dead by neurological criteria) for a period of time, usually only hours to days, rarely longer. Nevertheless, that individual is dead.
Death is the End of a Process
This process begins with an irreversible fact of health, namely the beginning of the failure of the integrative functions exerted by the brain and brain stem on the body. It ends with brain death and thus the death of the individual. Generally, this process involves an uncontrollable and progressive brain edema, causing the intracranial pressure to rise. When the intracranial pressure exceeds the systolic blood pressure, the heart is no longer capable of pumping blood through the brain. The swollen brain becomes compressed within its rigid ‘shell’, the skull, and herniates through the tentorium and the foramen magnum, which eventually totally blocks its own blood supply. Brain death and the death of the individual takes place as the end of this process. There is a second process which begins with the eath of the individual and involves the decomposition of the corpse and the ying of all the cells. The ancients were aware of these two processes and knew, for example, that hair and nails continue to grow for days after death. To think today that it is necessary to maintain the sub-systems of a corpse receiving artificial support, and to wait for the death of all the cells in the body before pronouncing the death of an individual would be to confuse these two processes. This latter approach has been termed ‘exaggerated treatment’ or, more specifically, the slowing down of the inexorable decomposition of a corpse through the use of artificial instruments.
The Consensus on Brain Death
The criterion of brain death as the death of an individual was established about forty years ago and since that time consensus on this criterion has increasingly grown. The most important academies of neurology in the world have adopted this criterion, as have most of the developed nations (the USA, France, Germany, Italy, the UK, Spain, the Netherlands, Belgium, Switzerland, Austria, India, Japan, Argentina and others) that have addressed this question. Unfortunately, there is insufficient explanation by the scientific world of this concept to public opinion which should be corrected. We need to achieve a convergence of views and to establish an agreed shared terminology. In addition, international organisations should seek to employ the same terms and definitions, which would help in the formulation of legislation. Naturally, public opinion must be convinced that the application of the criterion of brain death is carried out with the maximum rigour and efficacy. Governments should ensure that suitable resources, professional expertise and legislative frameworks are provided to ensure this end.
Statistics on Brain Death
In the USA, most of the statistics on cases of the diagnosis of recognised brain death since its full definition, its application, and the clinical histories involved are generally available in organ procurement offices. The Mayo Clinic has information on about 385 cases (years 1987-1996). Flowers and Patel (Southern Medical Journal 2000; 93:203-206), reported on 71 individuals who met the clinical criteria of brain death and then were studied by the use of radionuclide brain scans. No blood flow was demonstrated in 70 patients and in 1 patient arterial blood flow was present on the initial evaluation but disappeared 24 hours later. The authors concluded that using established medical criteria the accuracy of the diagnosis of brain death was 100%. The famous Repertinger meningitis case ironically demonstrates that it is possible to keep a body and organs perfused for a long period of time. One possibility is that this patient may not have been brain dead for a long period of time (cf. the detailed discussion on this possibility during the meeting and question 15, p. LXIX ff.). Another possibility is that this represents a valid case of brain death since all of the cinical tests were performed to ascertain brain death except the apnea test. The absent evoked potentials and the flat EEG were consistent with brain death. If this was a validly documented case of brain death, it makes the point that in extraordinarily rare exceptions this kind of case occurs. However, many years have passed since this case, there is a great deal of uncertainty about it, and one cannot generalise from it to invalidate the criteria for brain death. With the technologies available in modern intensive care units, we may see more of such prolonged cases, as technological capacity develops to reproduce some of the functions of the brain stem and hypothalamus in the integration and coordination of all the subsystems of the body. The neurological community does not believe that this case disturbs the conceptual validity of brain death as being equivalent to human death.
A Counterintuitive Reality
The history of science and of medicine contains many discoveries that are contrary to our perceptions and seem counterintuitive. Just as it was difficult for common sense to accept, at the time of Copernicus and Galileo, that the earth was not stationary, so it is sometimes difficult now for people to accept that a body with a pumping heart and a pulse is ‘dead’ and thus a corpse; ‘heart-beating death’ appears to defy our common sense perceptions. In part, this is because the dead brain, like the moving earth, cannot be seen, conceptualised, or experienced by the onlooker. Indeed, the common man does not easily accept that a deep sleep-like state with a heartbeat, accompanied by electrocardiogram activity, is death. Since the use of medical technology is so ubiquitous, it is easy to fail to comprehend that a ventilator machine is a necessary intermediary in maintaining this state. This may give rise to a deep-seated reluctance both to abandon brain-dead individuals and to accept the removal of organs from their bodies for the purposes of transplantation.
The concept of brain death has been at the centre of a philosophical and clinical debate, especially after advances made in the field of transplantations. In particular, it has been asked whether this criterion – and this is the view, for example, of Hans Jonas – was introduced to favour organ transplantations and is influenced by a dualistic vision of man that identifies what is specific to man with his cerebral activities. Yet, as emerged during discussions of the meeting, the criterion of brain death is compatible at a philosophical and theological level with a non-functionalist vision of man. St Augustine himself, who certainly did not identify the brain with the mind or the soul, was able to say that when ‘the brain by which the body is governed fails’, the soul separates from the body: ‘Thus, when the functions of the brain which are, so to speak, at the service of the soul, cease completely because of some defect or perturbation – since the messengers of the sensations and the agents of movement no longer act –, it is as if the soul was no longer present and was not [in the body], and it has gone away’ (De Gen. ad lit., L. VII, chap. 19; PL 34, 365). Indeed, the criterion of brain death is in conformity with the ‘sound anthropology’ of John Paul II, which sees death as the separation of the soul from the body, ‘consisting in the total disintegration of that unitary and integrated whole that is the personal self’. Thus, in relation to the criterion of brain death, the Pope was able to declare: ‘the criterion adopted in more recent times for ascertaining the fact of death, namely the complete and irreversible cessation of all brain activity (in the cerebrum, cerebellum and brain stem) if rigorously applied, does not seem to conflict with the essential elements of a sound anthropology’ (Cf. Address of 29 August 2000 to the 18th International Congress of the Transplantation Society).
From a clinical point of view, almost the whole of the medical community agrees that the concept of brain death as death should not serve an ulterior purpose (specifically: organ transplantation). Indeed, the ascertainment of brain death, which in historical terms was the result of the independent study of the brain, preceded the first transplantation procedures and thus was (and therefore is) unconnected with the related subject of transplants (cf., e.g., S. Lofstedt and G. von Reis, ‘Intracranial lesions with abolished passage of X-ray contrast throughout the internal carotid arteries’, PACE,
1956, 8, 99-202). Few physicians are convinced that the removal of organs from brain-dead individuals amounts to murder, and there is no reasonable legislation that adopts this point of view. The advent of cardiac and hepatic transplantation in the 1960s, and the need for organs from heart-beating donors to ensure successful results, generated an evident relationship between brain death and transplants. In the future, it is possible and to be hoped, that this relationship will diminish with new discoveries in the use of natural non-human and artificial organs.
Most of the arguments against brain death are not sustainable and are incorrect diversions when scrutinised from a neurological perspective. For example, the erroneous or imprecise application of the criteriaof brain death, the fact that the neurological examination in individual cases may be misinterpreted, or variations in the criteria chosen by specialist groups, can all too easily be used as spurious arguments against the concept.
The Apnea Test
The claims that apnea testing poses a risk to the patient are largely invalid when the testing is performed properly. Authorities should ensure that apnea testing is always carried out with the maximum of professional and technological expertise, and dedicate resources to this end.
Irreversible Situations: All Death is Brain Death
Assertions as to the existence of ‘awakenings’ from brain death have been used to discredit the concept and to prolong artificial ventilation, feeding and medical support in the hope of a recovery. A small number of cases of brain-dead individuals maintained in this state with ventilators and other medical measures for weeks, or even years, have given rise to unfounded claims that these subjects were in conditions other than death. In reality, as observed above in the section on ‘statistics on brain death’, where the proper diagnostic criteria have been employed all such assertions are not valid.
Pregnancies have been carried to term in brain-dead mothers. These cases are exceptional and do not involve potentially reversible conditions different from brain death. The mother’s uterus and other organs are being supported as a technical vessel for pregnancy, in much the same way that the heart or the kidneys are kept perfused. Thus, it is possible for an individual who is brain dead to give birth, if maintained with a ventilator, or other measures, for a certain period.
Antidiuretic and Other Pituitary Hormones
Other spurious arguments, such as the residual excretion of antidiuretic and other pituitary hormones in some cases of brain death, refer to tranient phenomena, and are technical arguments that can be dealt with on a practical level. There is no need for every single cell inside the cranium to be dead for brain death to be confirmed.
Recent reports of axon regeneration in patients with severe brain damage (which require corroboration and more study) are not pertinent to brain death.
It follows, as mentioned earlier, that there is no chance of recovery from brain death and that discussions regarding recovery from various states of coma must be distinguished from brain death.
The Need for an Expert Neurological Examination
If the criteria of brain death are rrectly applied, and if the neurological examination is carried out correctly by an experienced physician, then full reliability can be achieved. As mentioned above, there have been no documented exceptions. The neurological examination evaluates consciousness and reflexes to confirm death of the neurons involved in hese functions. Although every neuron in the central nervous system is not assessed during the examination, as stated earlier it is not necessary for absolutely all neurons to be dead for brain death to be reliably diagnosed. In a sedated or previously sedated patient, the lack of perfusion of the brain must be demonstrated for brain death to be ascertained beyond all doubt.
The Loss of Heart Activity
When the cardiologist pronounces death as a result of cardiac standstill, the diagnosis is less certain than in the circumstance of brain death. Many documented cases exist of patients pronounced dead after failure of cardiac resuscitation who have subsequently been discovered to be alive. It should be further stated that the traditional definition of natural loss of heart activity as ‘death’ is not satisfactory because it is now possible to keep the heart beating by artificial means and blood circulation to the brain can be maintained artificially to a brain that is dead. Confusionarises from the presence of mechanical systems that artificially replace the role of the brain as the generator of the functioning of essential organs.
Therefore, brain death is a much more certain diagnosis than heart death. The reluctance to accept brain death may be mostly related to the fact that it is a relatively new concept (the invention of the ventilator by Ibsen took place fifty-six years ago) compared to the traditionally accepted notion of cardiac and respiratory arrest.
The Loss of Breathing
If one proposes that the loss of spontaneous breathing defines death, then all brain-dead patients are, by definition, ‘dead’. When the patient has been pronounced dead after the application of the appropriate criteria of brain death, the decision to continue with ventilation can only be justified with reference to the life and wellbeing of another person.
No Ventilator, No Heart Activity
If one removes the ventilator from a brain-dead patient, the body under- goes the same sequence of events and physical dissolution as occurs in an individual who has undergone loss of heart activity.
Thus, it is as illogical to contend that death is the loss of heart activity as it is to affirm that the loss of kidney activity is death. Indeed, both renal activity (through dialysis) and heart activity (with a non-natural instrument) can be supported artificially, something that is impossible in the case of the brain: no artificial instrument exists that can reactivate or replace the brain after it has died.
No Circulation to the Brain Means Brain Death
One does not have to be a Cartesian to assert the central importance of the brain. Today, after advances in our knowledge of the workings of the brain, it is the medical-philosophical view that the body is ‘directed’ by that marvellous organ, the brain. Certainly, we are not a ‘brain in a vat’ but it has to be recognised that the brain is the receiving centre of all sensory, cognitive, and emotional experiences and that the brain acts as the neural central driving force of existence. We must acknowledge that the loss of circulation to the brain causes death. This loss of circulation can be documented in virtually all cases of brain death if tests are performed at the proper time.
The Camouflaging of Death
In reality, the ventilator and not the individual, artificially maintains the appearance of vitality of the body. Thus, in a condition of brain death, the so called life of the parts of the body is ‘artificial life’ and not natural life. In essence, an artificial instrument has become the principal cause of such a non-natural ‘life’. In this way, death is camouflaged or masked by the use of the artificial instrument.
Education and Brain Death
One of the tasks of physicians in general and neuroscientists is to educate the public about discoveries in this field. As regards the concept that all death is brain death, this task may be difficult, but it is our duty to continue in such an endeavour.
At a specific level, the relatives of brain-dead individuals should be told that their relative has died rather than that he is ‘brain-dead’, with the accompanying explanation that the support systems produce only an appearance of life. Equally, the terms ‘life-support’ and ‘treatment’ should not be employed because in reality support systems are being provided to a corpse.
A. Battro, J.L. Bernat, M.-G. Bousser, N. Cabibbo, Card. G. Cottier, R.B. Daroff, S. Davis, L. Deecke, C.J. Estol, W. Hacke, M.G. Hennerici, J.C. Huber, Card. A. López Trujillo, Card. C.M. Martini, J. Masdeu, H. Mattle, J.B. Posner, L. Puybasset, M. Raichle, A.H. Ropper, P.M. Rossini, M. Sánchez Sorondo, H. Schambeck, E. Sgreccia, P.N. Tandon, R. Vicuña, E. Wijdicks, A. Zichichi