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Brain Death: Another Pro-Life Issue?

'MODEST' DEBATE OVER DEATH CRITERIA

By Monica Seeley

The scenario is familiar from the news media: a tragic accident, a young victim, a distraught family. Follow-up stories within the next few days report approvingly of the donation of the brain dead patient's organs. The family expresses relief that some good has arisen from what could have been merely a senseless tragedy.

Most would find little controversy in donating a brain dead patient's organs, a routine procedure at both secular and religious hospitals throughout the world. However, a small but growing number of experts are protesting what they deem a too hasty rush to procure organs for transplant--so hasty, they contest, that so-called "brain dead" patients are in fact alive when they are put to the knife.

The Uniform Determination of Death Act (UDDA), adopted by most states, defines brain death as the "irreversible cessation of all functions of the entire brain, including the brain stem." The UDDA states that patients are legally dead when they fulfill either the traditional criteria for death (cessation of breathing and heartbeat) or when they are brain dead. Due to the use of artificial life support, many patients are now pronounced brain dead before heart and lungs stop. Although these individuals are legally dead, they may be kept on artificial life support in order to preserve their organs for transplant.

The term "brain death" entered common usage in the medical world around the same time that new technology made possible the first vital organ transplants. In 1968 the Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death stated "Our primary purpose is to define irreversible coma [i.e. brain death] as a new criterion for death." The report gave two reasons for this change: first, advances in medicine allowing brain damaged patients to survive on cardiac life support, and second, so- called "obsolete" criteria for the determination of death, coupled with the need for organs for transplant.

Dr. Christopher DeGiorgio, Associate Professor of Neurology and Neurological Surgery at the University of Southern California, explains: "Until the 1950s, there were no brain criteria for death. But with the advent of advanced cardiac life support, there were people who were being resuscitated from a heart attack or head trauma, who were put on life support which allowed them to breathe, and in whom the heart was working, but who had no evidence of brain function. For all intents and purposes, life was being maintained artificially. And at the same time, there was a tremendous need for organs, with the advent of transplantation. So we needed a way to verify that we were not transplanting organs from people who were alive, and to provide operational criteria or a working definition of death."

What does brain death "look" like? According to David Blake, former Director of the Bioethics Institute (affiliated with St. John's Hospital in Santa Monica) and current Executive Director of the Center for Health Care Ethics at the St. Joseph Health System in Orange, "on an experiential level, things don't look any different" than they would if the patient were in a coma. The patient is still breathing, his heart is beating, his color and blood pressure are normal. Blake describes the brain dead patient as "a decapitated body in a bed, with lungs being ventilated and the heart pumping." He adds, "What the law currently says is that even though that decapitated body in that bed still has a beating heart and the lungs are still being ventilated because it's hooked up to all these machines, that body is dead." While the patient may not look different than he did before being declared brain dead, legally he is now dead, and may be buried. The ventilator (sometimes called a respirator) may be turned off, and vital organs may be removed for transplant.

While criteria for brain death vary, generally doctors evaluate brain stem reflexes such as response of the pupil to light, response to ice-water in the ear, and gag and swallowing reflexes. The patient may be taken off the ventilator to determine whether spontaneous breathing is present. In addition, the cause of the coma must be known, and factors that could mimic brain death, such as certain potentially anesthetizing or paralyzing drugs, must be eliminated. The diagnosis may be confirmed with an EEG and a cerebral blood flow study, but these are optional. The State of California requires that two licensed physicians (not necessarily neurologists) make the diagnosis of brain death.

Both Blake and DeGiorgio feel that using the diagnosis of brain death to procure organs for transplant is positive and morally acceptable. DeGiorgio says, "When the organs of a brain-dead individual are transplanted, they can save the life of seven or eight people. You've got two kidneys, one heart, valve, lung, liver, corneas, all sorts of things that can benefit living people."

Dr. DeGiorgio, a Catholic, cites Pope Pius XII's 1957 address to the International Congress of Anesthesiologists, which alluded to a distinction between the life of an organism and the life of its cells. DeGiorgio interprets this as saying that "it was up to physicians to determine criteria for death." He says, "there was this idea that once the person had stopped functioning as an integrated organism, even though he may have a collection of organs that may be functioning independently, that person may be considered dead. The pope, from the late 1950s, recognized that indeed it was up to physicians to provide criteria for death in cases where the heart or the kidneys may still be functioning, but the brain is not functioning."

DeGiorgio admits that "There is some modest debate among theologians about if there really is something called brain death. But the Catholic church recognizes the validity of brain death guidelines." He is unable to cite an additional Vatican source for this statement.

The "modest debate" over brain death, to which Dr. DeGiorgio alludes, extends beyond theologians to physicians and bioethicists. The objection most frequently raised is that current criteria for determining brain death cannot adequately assess the presence or absence of irreversible coma. In a book entitled Life, Life Support, and Death (published by American Life League), nine physicians co-authors, argued that"Brain-related criteria are flawed not only in scientific theory but also in application. In order to fulfill the current 'brain death' criteria, the entire brain stem must not be functioning. In fact and in practice, however, often only some brain stem reflexes... are evaluated... Although there are other functions of the brain stem, including maintaining a normal body temperature, producing hormones via the hypothalamic-pituitary axis, neurogenic control of heart rate and maintenance of normal blood pressure, either these brain functions are not considered at all or they are said to be inapplicable or insignificant for determining death."

Bearing this out are accounts of patients who have been diagnosed as brain dead, and who have later recovered consciousness. Blake insists that the likelihood of this happening is "way beyond the pale," and "equal to people rising from the dead." DeGiorgio says "it's extremely rare." However, a casual search of pro-life resources soon reveals ten such cases, the most gruesome being that of a "brain dead" patient who put his arm around the assisting nurse as he was about to have his heart removed for transplant (Journal of California Nurses for Ethical Standards, September 1996).

Granted that such cases are relatively rare, and assuming that most organ donors are indeed legally brain dead, a more fundamental question remains. Are "brain dead" patients indeed dead? Is it correct to equate irreversible coma with death? According to Dr. Paul Byrne, one of the primary authors of Life, Life Support, and Death, the term coma, even irreversible coma, "is a term for someone who's alive, not someone who's dead."

A board-certified pediatrician and neonatologist who practices in Toledo, Ohio, Dr. Byrne has studied the subject of brain death for twenty years. His articles on the subject have been published in the Journal of the American Medical Association, the Gonzaga Law Review, and the Linacre Quarterly (the journal of the Catholic Medical Association).

Dr. Byrne believes that "To refer to someone who is in an intensive care unit on a ventilator, whose heart is beating, and [who has] blood pressure and other findings that we identify with being alive, as a cadaver, is simply not the truth." To illustrate this, he points out that harvested organs are referred to soon as harvested as "cadaveric", "like a cadaver", although later they may simply be called "cadaver organs."

In explaining brain death, David Blake cites the common argument that in a brain dead patient, the heart is beating, and the lungs are breathing, with the help of a ventilator, but without any brain function. However, Byrne claims that if respiration is truly occurring, as Blake claims, the patient must be alive. If the patient is truly dead, he says, although they may be attached to a ventilator, "the only thing that is occurring is that the chest is moving up and down. The chest moves up and down, but there is no exchange of oxygen and carbon dioxide, because in order to have exchange of oxygen and carbon dioxide, that involves an intact pulmonary system, an intact respiratory system. And for that system to carry out its function, there must be an intact circulatory system."

If a brain dead patient were dead, he states, the heart could not "do its thing for any great length of time without the other parts of the body." He adds, "The physiology of the body is for there to be an interdependence of organs and systems, to maintain the unity or the oneness or the healthiness of the body." While brain function is not necessary for the heart to beat, if the heart is beating without the aid of the brain stem, it will beat at a much slower rate than a normal heartbeat of neurogenic origin, and blood pressure will quickly drop.

Dr. DeGiorgio agrees that the heart "does function independently, however, when somebody is truly brain dead; after several days, the heart function deteriorates severely. So the heart may function temporarily without a functioning brain, but over a period of a couple days, a few days, the basic rhythm of the heart will deteriorate, and the patient's blood pressure will deteriorate. The heart is able to function independently for a few days, but it will progressively fail."

Thus, it is possible, by continuing to ventilate a brain dead patient, to test the diagnosis of death. If cardio-pulmonary death, that is, death in the classical sense, has occurred, in a short time the patient's heartbeat will slow and become irregular, despite continued ventilation. Eventually, no amount of artificial life support will be able to sustain the heartbeat. However, by the time this occurs, lack of oxygen may damage the vital organs. The deceased patient will no longer be a source of viable organs. Therefore, there is little interest in confirming death in this manner.

There may be a further reason why such confirmatory tests are not done, namely, that most "brain dead" patients are not truly dead. According to Dr. DeGiorgio, "You can keep somebody on life support for a few days or a few weeks at the longest, but generally people do not survive past two weeks who are truly brain-dead." Yet Dr. Byrne cites cases of brain dead individuals who have survived for long periods of time, even years. Further evidence is provided by Dr. Alan Shewmon in his article "Recovery from 'Brain Death': A Neurologist's Apologia" published in the Linacre Quarterly. Dr. Shewmon cites a collection of over thirty cases of protracted survival of brain-dead patients, ranging from one week to 9 months, with half of these patients surviving over eight weeks.

As further evidence, Dr. Byrne and his colleagues maintain that it is impossible to transplant vital organs from a corpse. According to Byrne, "The present state of the art for these vital organs is such that they have to come from someone who is alive. It takes about an hour of operating to get the heart out, during which time the heart has to be living, and many other organs and systems of the body are also functioning, while they take the heart out. Likewise, to get a liver out, it takes perhaps three hours of operating. Without circulation, the heart becomes not able to be used for transplant in about three or four minutes. Likewise the liver becomes not useful for transplant in about three or four minutes. Not useful for transplant means that the tissue of the heart or the tissue of the liver becomes destroyed so it's no longer what it was before."

If such reports of prolonged survival are relatively few, it could be because the diagnosis of brain death becomes a self-fulfilling prophecy. As Dr. Byrne notes wryly "No one ever recovers if their heart is cut out." Byrne points out that Pius XII's statement, cited by Dr. DeGiorgio, actually reads in full: "But considerations of a general nature allow us to believe that human life continues for as long as its vital functions--distinguished from the simple life of organs -- manifest themselves spontaneously or even with the help of artificial processes." According to Byrne, this quote, in which the Pope specifically refers to comatose patients, has been widely misquoted to read in part "unless with the help of artificial processes."

Byrne maintains that "brain death is not for diagnosing somebody who is dead. It's for creating a fiction for the determination of death, in order to get organs."

Oddly, Dr. DeGiorgio appears to agree with Byrne on this point. "From a purely metaphysical point of view," he says, "one can still argue that as long as the heart is beating, you have a human being. Again, [the definition of brain death] is a medical-legal definition, it is an artificial definition, because it is a criteria for death, but it doesn't mean that a variety of the individual organs aren't functioning. The word 'brain dead' is a misnomer. Technically the person is not dead, but legally he is, and in the medical community he's dead, even though he is a body with organs. What we're saying is that we have decided as a society that these individuals are no longer alive, and that we're defining death as either death of the heart or vascular system, or irreversible cessation of function of the brain. What we're talking about is a mechanism to allow us to withdraw life support."

Former University of Chicago professor James J. Hughes, Ph.D. states the position more clearly. In an address to the Second International Symposium on Brain Death (February 27-March 1, 1996), Hughes states baldly, "The death at issue in the brain death debate is not an empiric reality, but a social category, 'social death.' It is a question of which bodies we are comfortable using and disposing of in certain ways, and not comfortable giving medicine or food as if they were 'alive.'"

Dr. Byrne and his colleagues advocate a return to the traditional cardio-pulmonary standard for determining death, with the additional caveat that "No one shall be determined or declared dead unless and until there is destruction of at least the three basic unifying systems of the body, namely, the circulatory and respiratory systems, and the entire brain." Although the application of this standard "would preclude transplantation of unimpaired vital organs," they believe that "it is the only acceptable standard to ensure that living human beings are not treated with the scientifically inaccurate and morally repugnant haste that leads to a premature grave."

Ultimately, however, "the issue is not about organ transplantation" says Dr. Byrne. Instead, it is about the progressive devaluation of human life. He believes that the acceptance of brain death was a major step in the acceptance of abortion. Because of the 1968 Harvard Criteria defining irreversible coma as "brain death," he says, "the medical community accepted that absence of brain function was sufficient to call someone less than human. That was part of preparing them for the acceptance of abortion. If you have certain human beings in intensive care units, and you can call them something less than human, so that you can get organs, why can't you have other human beings that are out of sight in the uterus, and call them less than human so that we can kill them also, or use them for our own purposes?"

Dr. Byrne's concerns about the "slippery slope" are borne out in an article by Robert Truog, MD, entitled "Is It Time to Abandon Brain Death?" (Hastings Center Report, January-February 1997). Dr. Truog is Associate Professor of Anaesthesia at Harvard Medical School. Ironically, he cites an article by Byrne as one of his sources. Truog echoes Byrne's argument that brain dead patients are not dead, stating, "there is evidence that many individuals who fulfill all of the tests for brain death do not have the 'permanent cessation of functioning of the entire brain.'"

Dr. Truog notes that brain death criteria require the patient not to be hypothermic. This "is a particularly confusing Catch 22," he observes, because the absence of hypothermia indicates that the brain is still regulating body temperature. In addition, Truog states, "clinicians have observed that patients who fulfill the tests for brain death frequently respond to surgical incision at the time of organ procurement with a significant rise in both heart rate and blood pressure."

Yet Truog's conclusions are frighteningly similar to those of Byrne and colleagues. The concept of "brain death" is "incoherent in theory and confused in practice," he states, and recommends a return to the traditional definition of death, based on the cessation of respiration and circulation rather than neurological criteria. However, the problem of obtaining organs for transplant would remain. One way to solve this problem, he writes, "would be to abandon the requirement for the death of the donor prior to organ procurement and, instead, focus upon alternative and perhaps more fundamental ethical criteria to constrain the procurement of organs, such as the principles of consent and nonmaleficence." In other words, with the prior consent of the donor or surrogate, vital organs would be removed from living donors.

Truog notes approvingly that this approach would open the door to removing organs from PVS (Persistent Vegetative State) patients and anencephalic newborns. Both these groups are currently barred from being considered potential organ donors.

Truog observes "the most difficult challenge for this proposal would be to gain acceptance to the view that killing may sometimes be a justifiable necessity for procuring transplantable organs."

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