by Christian Ohnimus Wednesday, January 29
The Culture of Life naturally seeks to preserve human life and defend human dignity. This is a wonderful thing, but sometimes we can let our emotions get the best of us and, in our good intentions, argue from ignorance. This is often the case regarding the bogeyman of “brain death.” Its a scary medical term that we don’t always understand, summoning images of people, sometimes children, with beating hearts on life support, declared dead by a seeming technicality so that utilitarian doctors can harvest their organs, fresh and still warm. Its a chilling image indeed but its power is in emotion and not facts.
So, let’s lift the veil and take a look behind the curtain. What, exactly, is brain death and are the brain dead really “dead”? According to Catholic Health Care Ethics: A Manual for Practitioners brain death “typically refers to the irreversible loss of all functions of the entire brain, including the brain stem.” Blessed John Paul II affirmed the ethical use of brain death criteria in his address to the 18th international congress of the transplantation society Tuesday 29 August 2000, where he stated, “the total disintegration of that unitary and integrated whole that is the personal self” takes place when there is “the complete and irreversible cessation of all brain activity (in the cerebrum, cerebellum and brain stem). This is then considered the sign that the individual organism has lost its integrative capacity.”
Thus, for someone to be brain dead, their brain must cease functioning entirely and this cessation of function must be determined irreversible. Brain death is not the same thing as being in a coma or a vegetative state. There is no coming back. Yet, we’ve heard the stories of patients who were “brain dead” making miraculous recoveries. The truth is that they were never really brain dead and were declared such erroneously. Believe it or not, whether declaring brain or cardiac death, sometimes doctors are wrong. Its actually not always easy to tell if a patient has passed on. Thus, certain biological traits of death must be observed so that death may be declared with moral certainty.
To declare irreversible cessation of function of the brain, the patient is clinically examined and must be totally unresponsive, completely lacking all brain stem reflexes, and unbreathing. Additionally, the medical team rules out any conditions that may mimic death like locked-in syndrome, hypothermia or drug intoxication. Clinical examinations are often repeated after an interval of hours or even days of observation, sometimes multiple times by different doctors, and additional and more sophisticated testing may also be performed. All of these steps are not performed because brain death represents some hazy technicality but because it is important that, when declaring a patient dead, doctors can demonstrate with moral certainty that a genuine total loss of function has occurred and that this loss is irreversible. Highly sophisticated “life support” can give a dead body the vague appearance of life. A dead person may exhibit “residual biological functions.” For example, inotropic drugs can maintain a blood pressure even in a dead body and mechanical ventilation can inflate and deflate the lungs and “breathe” even after both the brain and heart have stopped. Life support can keep a body warm and pink long after the person has died and well perfused organs and tissue can still maintain some modicum of function even completely separated from the body. Hair can grow and wounds can heal; this is also why organ transplants are even possible at all in the first place. Transplanted hearts and kidneys remain alive the entire time as they make the journey from donor to recipient but that doesn’t mean that their original owner is still alive.
Kenneth Iserson, MD offers a good analogy for understanding just how concrete brain death is:
In death by brain criteria, the body is physiologically decapitated. In an anatomic decapitation, the head is actually chopped off but the heart continues to beat for some time, spraying blood from the severed neck arteries. Yet, despite the continued pumping of the heart, there is no question that the person is irreversibly dead.
The body, even when kept alive on machines, is no longer a living person when anatomically or physiologically cut off from the head. The tissues and organs may remain perfused but the person is gone. The death of the brain results in the disintegration of the person; the soul has departed and only the body remains. Any living tissue exists only in a mortally disintegrated state. To be brain dead is to be truly dead.
Circulatory-respiratory criteria, the criteria for declaring cardiac death, is far more straightforward. The heart stops beating and the patient’s code status determines whether efforts are made to resuscitate them. Either immediately after the heart stops or after exhaustive resuscitative efforts are made the patient is declared dead after two to five minutes of no circulation or respiration. It should be noted that, even in cardiac death, which to many has come to be viewed as “more dead” than brain death, organ function and even resuscitation can remain possible for a surprising amount of time. Two to five minutes is not long enough to guarantee irreversible loss of either cardiac or even brain function. To declare absolute certainty of death, even when adhering to circulatory-respiratory criteria, would require letting the patient sit cold on the table for hours. It could be days or longer before the body is no longer viable on the cellular level. Such would be an unduly burdensome as well as unnecessary endeavor both for medical professionals and families alike. Moral certainty suffices in declaring cardiac death and it suffices in declaring brain death as well.
It should be clear from this explanation of brain and cardiac death that a patient who is brain dead is actually dead and not merely declared so on technicalities for convenient legal purposes. In fact, the diagnosis of “brain dead” is far more rigorous and exhaustive than that of cardiac death which, while truly irreversible when properly diagnosed, can occur before the brain has actually lost all function irreversibly – meaning that metaphysical (and brain) death may yet still occur some minutes after cardio-respiratory arrest (cardiac death).
Brain death is not something to fear. The neurological criteria to determine death is a tool, one we must seek to understand so as to assure that it is used properly. The conversation does not end here. Real problems exist regarding brain death. Brain death is misdiagnosed, abused, and confused and we must possess a mature moral and medical understanding in combating such ailments lest our good intentions be drowned by our ignorance. I will address the issues surrounding brain death’s misapplication next week.
Christian Ohnimus is a husband and registered nurse in Grand Rapids, Michigan. He holds a Bachelors of Science in Nursing from Franciscan University. He hopes to raise a holy family with the help of his better and more beautiful other half.