"Brain Death" is Not Death! "Brain Death" is Not Death!
Essay - At a meeting of the Pontifical Academy of Sciences in early
February
"Brain Death"
is Not Death!
In medicine we protect, preserve, and prolong life and postpone death . . . Our goal is to keep body and soul united. When a vital organ ceases to function, death can result. On the other hand, medical intervention can sometimes restore the function of the damaged organ, or medical devices (such as pacemakers and heart-lung machines) can preserve life. The observation of a cessation of functioning of the brain or some other organ of the body does not in itself indicate destruction of even that organ, much less death of the person.
Dr Paul Byrne
By Paul A. Byrne, Cicero G. Coimbra, Robert Spaemann, and Mercedes Arzú Wilson
On February 3-4, the
Pontifical Academy of Sciences, in cooperation with World Organization for the
Family, hosted a meeting at the Vatican entitled “The Signs of Death.” This
essay is based on the papers that were submitted to the Pontifical Academy as
well as the discussions that took place during those two days.
The meeting was convened at the request of Pope John Paul II to re-assess the
signs of death and verify, at a purely scientific level, the validity of
brain-related criteria for death, entering into the contemporary debate of the
scientific community on this issue.
In a message to the Pontifical Academy of Sciences, made public at the February
meeting, the Holy Father said that the Church has consistently supported "the
practice of transplanting organs from deceased persons." However, he cautioned
that transplants are acceptable only when they are conducted in a manner "so as
to guarantee respect for life and for the human person."
The Pope cited his predecessor, Pope Pius XII, who said that "it is for the
doctor to give a clear and precise definition of death and of the moment of
death." He encouraged the Pontifical Academy to pursue that task, promising that
scientists could count on the support of Vatican officials, "especially the
Congregation for the Doctrine of the Faith."
Background
In 1968 the “Harvard criteria” for determining brain death were published in the
Journal of the American Medical Association, under the title of “A Definition of
Irreversible Coma.” This article was published without substantiating data,
either from scientific research or from case studies of individual patients. For
this reason, a majority of the presenters at the conference in Rome stated that
the “Harvard criteria” were scientifically invalid.
In 2002 the results of a worldwide survey were published in Neurology,
concluding that the use of the term “brain death” worldwide is “an accepted fact
but there was no global consensus on the diagnostic criteria” and there are
still “unresolved issues worldwide.” In fact between 1968 and 1978 at least 30
disparate sets of criteria were published, and there have been many more since
then. Every new set of criteria tends to be less rigid than earlier sets and
none of them is based on the scientific method of observation and hypothesis
followed by verification).
Attempts to compare the newer criteria with the time proven, generally accepted
criteria for death--the cessation of circulation, respiration, and
reflexes--show that these criteria are distinctly different. This has resulted
in an unhappy situation for the medical profession. Many physicians, who feel
that the Hippocratic Oath is being violated by acceptance of such disparate sets
of criteria, feel the need to expose the fallacy of “brain death,” because the
noble reputation of the medical profession is at stake.
Philosophical considerations
In his presentation to the Pontifical Academy, Robert Spaemann--a noted former
professor of philosophy from the University of Munich--cited the words of Pope
Pius XII, who declared that "human life continues when its vital functions
manifest themselves, even with the help of artificial processes.”
Professor Spaemann observed: "The cessation of breathing and heartbeat, the
‘dimming of the eyes,’ rigor mortis, etc. are the criteria by which since time
immemorial humans have seen and felt that a fellow human being is dead." But the
Harvard criteria "fundamentally changed this correlation between medical science
and normal interpersonal perception." As he put it:
Scrutinizing the existence of the symptoms of death as perceived by common
sense, science no longer presupposes the “normal” understanding of life and
death. It in fact invalidates normal human perception by declaring human beings
dead who are still perceived as living.
The new approach to defining death, the German scholar continued, reflected a
different set of priorities:
It was no longer the interest of the dying to avoid being declared dead
prematurely, but other people’s interest in declaring a dying person dead as
soon as possible. Two reasons are given for this third party interest:
1) guaranteeing legal immunity for discontinuing life-prolonging measures that would constitute a financial and personal burden for family members and society alike,
and
2) collecting vital organs for the purpose of saving the lives of other
human beings through transplantation. These two interests are not the patient’s
interests, since they aim at eliminating him as a subject of his own interests
as soon as possible.
The arguments against the use of "brain death" as a determination of death are
being made, Spaemann noted, "not only by philosophers, and, especially in my
country, by leading jurists, but also by medical scientists." He quoted the
words of a German anesthesiologist who wrote, "Brain-dead people are not dead,
but dying."
Medical evidence
Dr. Paul Byrne, a neonatologist from Toledo, Ohio, offered a medical perspective
- he testified:
When organs are removed from a "brain dead" donor, all the vital signs of the
“donors” are still present prior to the harvesting of organs, such as: normal
body temperature and blood pressure; the heart is beating; vital organs, like
the liver and kidneys, are functioning; and the donor is breathing with the help
of a ventilator.
Furthermore, Bryne told the Academy, that approach is required for most
transplant surgery, because vital organs deteriorate very quickly after a
patient dies. "After true death," he said, "unpaired vital organs (specifically
the heart and whole liver) cannot be transplanted.”
Transplantation of unpaired vital organs is legal in most Western countries,
including the United States, and in some developing nations like Brazil, but the
important question for anyone is: “is it morally permissible to terminate a life
to save another?" Pope John Paul II has repeatedly said as recently as February
4, 2003 message to the World Day of the Sick: “It is never licit to kill one
human being in order to save another." The Catechism of the Catholic Church
clearly states (2296): “It is morally inadmissible directly to bring about the
disabling mutilation or death of a human being, even in order to delay the death
of other persons.”
"In medicine we protect, preserve, and prolong life and postpone death," Byrne
said. "Our goal is to keep body and soul united." When a vital organ ceases to
function, he argued, death can result. On the other hand, medical intervention
can sometimes restore the function of the damaged organ, or medical devices
(such as pacemakers and heart-lung machines) can preserve life. He said: "The
observation of a cessation of functioning of the brain or some other organ of
the body does not in itself indicate destruction of even that organ, much less
death of the person."
Defending the criteria
Some participants in the February meeting defended the use of the "brain death"
criteria. Dr. Stewart Youngner of Case Western University in Ohio admitted that
“brain dead” donors are alive, but argued that this should not prove an
impediment to the harvesting of their organs. His reasoning was that there is
such poor “quality of life” in the “brain dead” patient that it would be more
beneficial to harvest their organs to extend the life of another than to
continue the life of the organ donor.
Dr. Conrado Estol, a neurologist from Buenos Aires, explained the steps that
should be followed in determining the "brain death" of a prospective organ
donor. Dr. Estol, who is strongly in favor of harvesting human organs to extend
the life of other patients, presented a dramatic video of a person diagnosed as
“brain dead” who attempted to sit up and cross his arms, although Dr. Estol
assured the audience that the donor was a cadaver. This produced an unsettling
response among many participants at the conference.
A French transplant surgeon, Dr. Didier Houssin, acknowledged the difficulties
that arise because of the discrepancies between the different criteria for brain
death. He observed that "death is a medical fact, a biological process, and a
philosophical question, but it is also a social fact. It would be difficult for
a society to admit that a man could be said alive in one place and dead in
another place. However, as a proponent of transplants, he said that it is
important for society to trust doctors.
Another French physician, Dr. Jean-Didier Vincent of the Institut
Universitaire, emphasized that a “brain dead” person has suffered complete and
irreversible destruction of the brain. Dr. Vincent was questioned closely about
the case of a pregnant women, diagnosed as brain-dead, who continues her
pregnancy while on life-support system, even producing breast milk for her
unborn child. He admitted that the mother produces milk, but regards that
production as an inhibited mechanical reflex rather than a sign of enduring
human life. When reminded that the production of breast milk results from the
signal sent from the anterior lobe of the pituitary that stimulates the
secretion of milk, and possibly breast growth, thus requiring a functioning
brain, he replied that there could be some minimal hormonal production in the
brain.
The apnea test
In his presentation at the conference, Dr. Cicero Coimbra, a clinical
neurologist from the Federal University of Sao Paolo, Brazil denounced the
cruelty of the apnea test, in which mechanical respiratory support is withdrawn
from the patient for up to 10 minutes, to determine whether he will begin
breathing independently. This is part of the procedure before declaring a
brain-injured patient “brain dead.” Dr. Coimbra explained that this test
significantly impairs the possible recovery of a brain-injured patient, and can
even cause the death of the patients. He argued:
. A large number of brain-injured patients, even in deep coma, can recover to
lead a normal daily life; their nervous tissue may be only silent, not
irreversibly damaged, as a consequence of a partial reduction of the blood
supply to the brain. (This phenomenon, called “ischemic penumbra,” was not known
when the first neurological criteria for brain death were established 37 years
ago.) However, the apnea test (considered the most important step for the
diagnosis of “brain death” or brain-stem death) may induce irreversible
intra-cranial circulatory collapse or even cardiac arrest, thereby preventing
neurological recovery.
· During the apnea test, the patients are prevented from expelling carbon
dioxide (CO2), which becomes a poison to the heart as the blood CO2
concentration rises.
· As a consequence of this procedure, the blood pressure drops, and the blood
supply to the brain irreversibly ceases, thereby causing rather than diagnosing
irreversible brain damage; by reducing the blood pressure, the “test” further
reduces the blood supply to the respiratory centers in the brain, thereby
preventing the patient from breathing during this procedure. (By breathing, the
patient would demonstrate that he is alive.)
· Irreversible cardiac arrest (death), cardiac arrhythmias, myocardial
infarction, and other life-threatening detrimental effects may also occur during
the apnea test. Therefore, irreversible brain damage may occur during and before
the end of the diagnostic procedures for “brain death.”
Dr. Coimbra concluded by saying that the apnea test should be considered
unethical and declared illegal as an inhumane medical procedure. If family
members were informed of the brutality and risk of the procedure, he stated,
most of them would deny permission.
He pointed out that when a heart attack patient is admitted to the emergency room he is never subjected to a stress test in order to verify that he is suffering from heart failure. Instead the patient is given special care and protection from further stress to the heart.
In contrast when a brain-injured patient is subjected to the apnea
test, further stress is placed on the organ that has already been injured, and
additional damage can endanger the patient’s life. Dr. Yoshio Watanabe a
cardiologist from Nagoya, Japan, concurred, saying that if patients were not
subjected to the apnea test, they could have a 60 percent chance of recovery to
normal life if treated with timely therapeutic hypothermia.
The question of a brain-injured patient's possible recovery also concerned
Dr. David Hill, a British anesthetist and lecturer at Cambridge. He observed:
"It should be emphasized first that it was widely admitted, that some functions,
or at least some activity, in the brain may still persist; and second that the
only purpose served by declaring a patient to be dead rather than dying, is to
obtain viable organs for transplantation." The use of these criteria, he
concluded, "could in no way be interpreted as a benefit to the dying patient,
but only (contrary to Hippocratic principles) a potential benefit to the
recipient of that patient’s organs."
"The deception"
Dr. Hill recalled that the earliest attempts at transplanting vital organs often
failed because the organs, taken from cadavers, did not recover from the period
of ischemia following the donor's death. The adoption of brain-death criteria
solved that problem, he reported, "by allowing the removal of vital organs
before life support was turned off--without the legal consequences that might
otherwise have attended the practice.”
While it is remarkable that the public has accepted these new criteria, Dr. Hill
remarked, he attributed that acceptance in large part to the favorable publicity
for organ transplants, and in part to public ignorance about the procedures.
"It is not generally realized," he said, that life support is not
withdrawn before organs are taken; nor that some form of anaesthesia is needed
to control the donor whilst the operation is performed.” As knowledge of the
procedure increases, he observed, it is not surprising that--as reported in a
2004 British study--"the refusal rate by relatives for organ removal has risen
from 30 percent in 1992 to 44 percent." Dr. Hill also suggested that when
relatives see with their own eyes the evidence that a potential organ donor is
still alive, they harbor enough doubts so that they are not ready to consent to
the organ removal.
In the United Kingdom, Dr. Hill reported, there is mounting pressure for
individuals to sign, and always carry with them, donor cards authorizing doctors
to use their vital organs. Today only about 19 percent of the country's people
have registered as organ donors, but vehicle-registration forms,
driver's-license applications, and other public documents provide "tick boxes"
allowing citizens to give this advance directive; even children are encouraged
to sign. All such documents specify that organs may be harvested only "after my
death," but there is no definition of what constitutes "death." Again, Dr. Hill
remarked, the acceptance of transplants hangs on the public's lack of
understanding about the procedure. And yet, he pointed out, "For any other
procedure, informed consent is required, but for this most final of operations
no explanation nor counter-signature is required, nor is the opportunity given
to discuss the question of anaesthesia."
Bishop Fabian Bruskewitz of Lincoln, Nebraska, addressed the issue of the
donor's consent. “As far as I know," he told the Pontifical Academy, "no
respectable, learned and accepted moral Catholic theologian has said that the
words of Jesus regarding laying down one’s life for one’s friends (John 15:13)
is a command or even a license for suicidal consent for the benefit of another’s
continuation of earthly life.”
The bishop went on to observe that current technology enables doctors only to
monitor brain activity "in the outer 1 or 2 centimeters of the brain." He asks:
"Do we have then, moral certitude in any way that can be called apodictic
regarding even the existence, much less the cessation of brain activity?” From
the perspective of Catholic moral teaching the bishop said:
The dignity and autonomy of a human being--whether zygote, blastocyst,
embryo, fetus, newborn, infant, adolescent, adult, disabled or handicapped
adult, aged adult, adult in a comatose or (so-called) persistent vegetative
state, etc--are viewed, as they have been viewed throughout the history of the
Catholic Church, as worthy of respect and entitled to protection from untoward
human intervention effecting the termination of human life at any of those
stages.
In light of the serious questions about the validity of the "brain death"
criteria, Professor Josef Seifert from the International Academy of Philosophy
in Liechtenstein argued that medical ethicists should invoke the true and
evident ethical principle (emphasized by the whole Church tradition of moral
teachings), that "even if a small reasonable doubt exists that our acts kill
a living human person, we must abstain from them.”
The Signs of Death
Conclusions reached after examination of Brain-Related Criteria for death, at
the Pontifical Academy of Sciences meeting
1. On the one hand the Church recognizes, consistent with her tradition, that
the sanctity of all human life from conception to natural end must absolutely be
respected and upheld. On the other hand, a secular society tends to place
greater emphasis on the quality of living.
2. The Catholic Church has always opposed the destruction of human life before
being born through abortion and she equally condemns the premature ending of the
life of an innocent donor in order to extend the life of another through
unpaired vital organ transplantation. "It is morally inadmissible directly to
bring about the disabling mutilation or death of a human being, even in order to
delay the death of other persons." “It is never licit to kill one human being in
order to save another."
3. "Nor can we remain silent in the face of other more furtive, but no less
serious and real forms of euthanasia. These could occur for example when, in
order to increase the availability of organs for transplants, organs are removed
without respecting objective and adequate criteria which verify the death of the
donor."
4. "The death of the person is a single event, consisting in the total
disintegration of that unitary and integrated whole that is the personal self.
It results from the separation of the life-principle (or soul) from the corporal
reality of the person." Pope Pius XII declared this same truth when he stated
that human life continues when its vital functions manifest themselves even with
the help of artificial processes.
5. "Acknowledgement of the unique dignity of the human person has a further
underlying consequence: vital organs which occur singly in the body can be
removed only after death--that is, from the body of someone who is certainly
dead. This requirement is self-evident, since to act otherwise would mean
intentionally to cause the death of the donor in disposing of his organs.”
Natural moral law precludes removal for transplantation of unpaired vital organs
from a person who is not certainly dead. The declaration of "brain death" is not
sufficient to arrive at the conclusion that the patient is certainly dead. It is
not even sufficient to arrive at moral certitude.
6. Many in the medical and scientific community maintain that brain-related
criteria for death are sufficient to generate moral certitude of death itself.
Ongoing medical and scientific evidence contradicts this assumption.
Neurological criteria alone are not sufficient to generate moral certitude of
death itself, and are absolutely incapable of generating physical certainty that
death has occurred.
7. It is now patently evident that there is no single so-called neurological
criterion commonly held by the international scientific community to determine
certain death. Rather, many different sets of neurological criteria are used
without global consensus.
8. Neurological criteria are not sufficient for declaration of death when an
intact cardio-respiratory system is functioning. These neurological criteria
test for the absence of some specific brain reflexes. Functions of the brain not
considered are temperature control, blood pressure, cardiac rate and salt and
water balance. When a patient on a ventilation machine is declared “brain dead,"
these functions not only are present but also are frequently active.
9. The apnea test--the removal of respiratory support--is mandated as a part of
the neurological diagnosis and it is paradoxically applied to ensure
irreversibility. This significantly impairs outcome, or even causes death, in
patients with severe brain injury.
10. There is overwhelming medical and scientific evidence that the complete and
irreversible cessation of all brain activity (in the cerebrum, cerebellum and
brain stem) is not proof of death. The complete cessation of brain activity
cannot be adequately assessed. Irreversibility is a prognosis, not a medically
observable fact. We now successfully treat many patients who in the recent past
were considered hopeless.
11. A diagnosis of death by neurological criteria alone is theory, not
scientific fact. It is not sufficient to overcome the presumption of life.
12. No law whatsoever ought to attempt to make licit an act that is
intrinsically evil. "I repeat once more that a law which violates an innocent
person's natural right to life is unjust and, as such, is not valid as a law.
For this reason I urgently appeal once more to all political leaders not to pass
laws which, by disregarding the dignity of the person, undermine the very fabric
of society."
13. The termination of one innocent life in pursuit of saving another, as in the
case of the transplantation of unpaired vital organs, does not mitigate the evil
of taking an innocent human life. Evil may not be done that good might come of
it.
Signatories:
J.A. Armour, physician, University of Montreal Hospital of the Sacred Heart,
Montreal, Quebec.
Fabian Bruskewitz, Bishop of Lincoln, Nebraska
Paul A. Byrne, past president, Catholic Medical Association, US.
Pilar Mercado Calva, professor, School of Medicine, Anahuac University, Mexico.
Cicero G. Coimbra, professor of Clinical Neurology, Federal University of Sao
Paolo, Brazil.
William F. Colliton, retired professor of Obstetrics and Gynecology George
Washington University Medical School, Virginia.
Joseph C. Evers, clinical associate professor of Pediatrics, Georgetown
University School of Medicine, Washington, DC.
David Hill, emeritus consultant anesthetist, at Addenbrooke’s Hospital, and
associate lecturer, Cambridge University, England.
Ruth Oliver, psychiatrist, Kingston, Ontario.
Michael Potts, head of Religion and Philosophy Department, Methodist College,
Fayetteville, North Carolina.
Josef Seifert, professor of Philosophy at the International Academy of of
Philosophy, Vaduz, Liechtenstein; honorary member of the Medical Faculty of the
Pontifical Catholic University of Chile in Santiago, Chile.
Robert Spaemann, professor emeritus of Philosophy, University of Munich,
Germany.
Robert F. Vasa, Bishop of the Diocese of Baker, Oregon.
Yoshio Watanabe, consultant cardiologist, Nagoya Tokushukai General Hospital,
Japan.
Mercedes Arzú. Wilson, president, Family of the Americas Foundation and World
Organization for the Family.
Source: Essay - meeting of the Pontifical Academy of Sciences
in early February ---
Dr Paul Byrne, to The Compassionate Healthcare Network, March
29, 2005 via e-mail
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