Brain Death

Outline

• Truog argues that the concept of brain death (as currently understood) is inconsistent and that it might be best to abandon it altogether

– Describes concept

– Shows that it is internally inconsistent

– Considers alternative criteria for determining death has occurred

• Concludes that we should return to the cardiorespiratory standard

– Works out the implications of his conclusion for organ donation

Brain Death

• Traditional view: death has occurred when breathing and heart beat cease

• BUT we can now use machines to replace heart and lung function

• “Brain death” has therefore become an accepted standard

Why is brain death a good alternative standard?

• Allows for action in cases where attempts to revive an individual are unsuccessful: can stop mechanical support without committing euthanasia

• Agrees with our intuition regarding personhood (who we are depends on our brain…)

• Permits organs to be harvested for transplant

The “whole brain” standard

President’s Commission, 1981

• Irreversible cessation of circulatory or respiratory functions OR

• Irreversible cessation of all functions of the entire brain, including the brain stem

– The first is an indication of the second

Three levels of analysis

• Definition of death: “permanent cessation of functioning of the organism as a whole”

• Criterion for death: “permanent cessation of function of the entire brain”

• Tests for death: cardiorespiratory tests or neurological tests

Definition, criterion, tests?

• What is death?

• Definition answers this question

• How do we know death has occurred?

• Criterion gives a general standard

• Tests are more specific

Tests

• Cardiorespiratory standard – prolonged absence of vital signs

– This standard also fulfills the criterion of cardiorespiratory death

• Neurological standard – battery of tests and procedures. Includes knowledge of etiology.

Are these levels consistent?

• If “yes,” the definition, criterion and tests must all be consistent

• That is, (1) fulfilling the medical tests must mean satisfying the criterion and (2) satisfying the criterion must mean satisfying the definition

• Truog: neither (1) nor (2) are true; concept of brain death is not consistent

• Tests/criterion are not consistent:

– An individual who “fails” the tests may still have some brain activity: body temperature, hormonal homeostasis. Also physiological response to surgical incision at organ removal.

– Using the cardiorespiratory standard instead guarantees that the person judged dead is actually dead, but means that organs cannot be harvested

• Can they be made consistent?

– Better neurological tests

– Not likely

– Reliance on cardiorespiratory test only

– But law would prohibit organ donation

• Criterion/definition are not consistent

– The whole brain concept assumes that the criterion necessarily implies the definition

– This view is based on the fact that the brain regulates homeostasis; if the brain is not functioning properly, then “the organism rapidly disintegrates”

– But “rapid disintegration” means that the organism is dying not that it is dead. So the criterion is not diagnostic of death, but prognostic.

– Also assumes that the brain is irreplaceable – but the ICU can act as a “surrogate brainstem”

• Pregnant women who are brain dead

• Brain dead patients awaiting organ harvesting

Why do we want consistency?

• May not need it if we can still set good policy

• But, medicine does seek to be based on a solid theoretical and conceptual basis

• Also, there is evidence to link this inconsistency with confusion among clinicians, laypersons

– Good reasons for avoiding this confusion

Two Alternatives…

…to the whole-brain criterion

• “Higher brain” criterion

• Return to cardiorespiratory standard

Higher-Brain Criterion

• Death would be identified with permanent loss of consciousness

• This accords with our understanding of what it means to be a person (“higher” brain functions)

• Would include two groups not included by current “whole-brain standard”

– Permanent vegetative state

– Anencephalic newborns

• There would be problems with this standard, as well

– Diagnosis of permanent unconsciousness is difficult

– Distinction between death of the person and death of the organism

– Breathing, but dead?

• Burial or cremation

• “Living remains”

Cardiorespiratory Criterion

• This is the traditional criterion; Truog considers whether we should return to it

• He looks at the reasons that it was initially rejected in favour of the current whole-brain standard

Truog identifies four questions addressed by the Harvard committee:

• When is it permissible to withdraw life support for the benefit of the patient?

• …for the benefit of society?

• When is it permissible to remove organs?

• When is a person ready to be buried?

• The Harvard Committee gave one answer to all of these questions

• Considering them separately may give us a better way to find an alternative to brain death

1. Withdrawal of life support

• Harvard committee: brain death as necessary condition for withdrawal of life support

• Since then, there has been a change in the acceptability of withdrawing treatment – the wishes of the patient (or surrogate) are followed

2. Allocation of scarce resources

• Should patients with a hopeless prognosis occupy scarce ICU beds?

• This problem is actually rare (in part because of withdrawal of treatment) and so has little impact on resource availability

4. When should a person be cremated or buried?

• “Even today we uniformly regard the cessation of respiration and circulation as the standard for determining when patients are ready to be cremated or buried.”

• Greater degree of agreement about this than about brain death (some religious and cultural traditions do not accept the concept of brain death)

Organ Donation in Canada

• 2006 – 3974 patients waiting for organ donation (up from 2592 in 1995)

• Canada has 12.8 donors per million population

– Spain has 35.1

– U.S. has 21.5

– Belgium 22.8

• Nearly 98% of kidney transplants, 90% of liver transplants and 85% of heart transplants are successful

• Canadian practice – those willing to donate “opt in” through signing an organ donor card, or through explicit consent of surviving family

• Canadian Council for Donation and Transplantation established by Health Canada in 2001

– Raise public awareness about the need for donor organs

– Improve coordination of donor process between regions, provinces

3. Organ transplantation

• Truog: the most important question

• Is brain death an ethical and legal justification for harvesting organs?

• Some attempts have been made to circumvent the need for a diagnosis of brain death before organ harvesting

• Methods and justifications of these protocols is “contrived and even somewhat bizarre”

• “How can the legitimate desire to increase the supply of transplantable organs be reconciled with the need to maintain a clear and simple distinction between the living and the dead?”

• Could abandon criterion for brain death and focus instead on ethical criteria, such as consent, nonmaleficence

• “Even now, surveys show that one-third of physicians and nurses do not believe brain-dead patients are actually dead, but feel comfortable with the process of organ procurement because the patients are permanently unconscious and/or imminently dying.”

Different definitions?

• One alternative – different definitions of death depending on purpose or preference?

• Purposes: one definition for organ harvesting and another for burial

• Preference: individuals could choose a definition of death that ranged from cardiorespiratory standard through to permanent unconsciousness (Emanuel)

– Would permit individuals to request or to reject organ donation, depending on the definition they choseA dilemma

• We want to be able to procure transplantable organs and we want a conceptually coherent account of death…

– Current standards for organ donation require brain death

– Current standards re burial (“real death”?) require cardiorespiratory death

A solution?

• Truog suggests that we solve the dilemma by returning to the cardiorespiratory definition of death and saying that “killing may sometimes be a justifiable necessity for procuring transplantable organs”

Justification of organ harvesting

• Troug’s suggestion would require that we find a different justification for harvesting organs

– Current justification is that (1) the patient is dead and (2) the patient/family have given permission

• The return to the cardiorespiratory standard would mean that we would be killing a living person in order to harvest his/her organs

• To justify this, we would need (1) consent/permission and (2) principle of nonmaleficence

– Could only harvest organs from someone who would not be harmed by the procedure

Consent?

• Ontario: recent proposed change from “opting in” for organ donation to “opting out”

– Tacit consent

• Would this change our views on whether we could harvest organs from someone who is still “technically” alive?

– Is nonmaleficence enough?

Gaylin

• Raises a similar point to Wikler, but arrives at it differently:

• “Pulling the plug” on a brain dead patient is not viewed as euthanasia because the patient is dead

• But if brain death “grants the right to pull the plug, it also implicitly grants the privilege not to pull the plug”

Enter the neomort

• Cadavers maintained on life support would be legally dead, but would be “warm, respiring, pulsating, evacuating and excreting bodies requiring nursing, dietary and general grooming attention”

We now permit and accept

• Dead donors

– Autopsies

– Use of cadavers for teaching purposes

– Organ donation

• Living donors

– Tissue/cell donation (blood and compounds, sperm), also skin, muscle transplants

Why not use neomorts?

• “Whatever is possible with the old embalmed cadaver is extended to an incredible degree with the neomort”

– Training (physical examination, diagnostic procedures, surgical techniques”

– Testing (drug physiology, toxicology)

– Experiments (instead of animal research)

– Banking of organs, tissues

– Harvesting of organs as needed

– “Manufacture” of hormones, antibodies

Cost-benefit analysis:
economic issues

• If we can find one economically sound reason for maintaining neomorts, we get all of the other benefits “for free” (gratuitous byproducts)

• Switching to a “higher brain” rather than “whole brain” definition of brain death would save money

Cost-benefit analysis:
other costs?

• “Cost-benefit analysis is always least satisfactory when the costs must be measured in one realm and the benefits in another.”

– What would the costs be of using neomorts?

The “Ick” factor

• What is the source of the problem that many people have with neomorts?

– Autopsies

– Abdominal surgery

– Disposing of the dead (cremation, organ donation)

– Test-tube babies

– Cloning

• Is the “ick factor” a product of ignorance and superstition or a sign that we have reached a boundary that we shouldn’t cross?